1053646596 NPI number — MRS. MIKELLE MONIQUE ROMO OTR/L

Table of content: MRS. MIKELLE MONIQUE ROMO OTR/L (NPI 1053646596)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053646596 NPI number — MRS. MIKELLE MONIQUE ROMO OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROMO
Provider First Name:
MIKELLE
Provider Middle Name:
MONIQUE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROMO
Provider Other First Name:
MIKI
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR/L
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1053646596
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1530 5TH AVE
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
SAN RAFAEL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94901-1816
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-457-7745
Provider Business Mailing Address Fax Number:
415-453-9685

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1530 5TH AVE
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
SAN RAFAEL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94901-1816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-457-7745
Provider Business Practice Location Address Fax Number:
415-453-9685
Provider Enumeration Date:
10/15/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XP0200X , with the licence number:  OT5997 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com