1184828964 NPI number — LOUELLA M REGIS MD

Table of content: LOUELLA M REGIS MD (NPI 1184828964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184828964 NPI number — LOUELLA M REGIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REGIS
Provider First Name:
LOUELLA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REGIS
Provider Other First Name:
MARIA
Provider Other Middle Name:
AGUSTINA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184828964
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 649
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT DEFIANCE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86504-0649
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
911 WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALISTOGA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94515-1433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-709-2308
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/13/2007

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: 207Q00000X , with the licence number:  4301083835 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MD-15277 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: A101548 , 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)

  • Identifier: 634825-02 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000286773 . This is a "HMSA BILLING NUMBER" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 00A1015480 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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