1073797189 NPI number — DAE LLC

Table of content: (NPI 1073797189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073797189 NPI number — DAE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DAE THERAPY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073797189
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/26/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
113 WEST FIRE TOWER RD.
Provider Second Line Business Mailing Address:
SUITE G
Provider Business Mailing Address City Name:
WINTERVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28590-8377
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-758-1300
Provider Business Mailing Address Fax Number:
252-758-0015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
113 W FIRETOWER RD
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
WINTERVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28590-8377
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-758-1300
Provider Business Practice Location Address Fax Number:
252-758-0015
Provider Enumeration Date:
12/26/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BARNETT
Authorized Official First Name:
EMMANUEL
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
704-591-2927

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  1021 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 5318 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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