1316223076 NPI number — JAXIE GUNNER, INC.

Table of content: (NPI 1316223076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316223076 NPI number — JAXIE GUNNER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JAXIE GUNNER, INC.
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:
Provider Other Organization Name Type Code:
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:
1316223076
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
408 8TH ST
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
NEW KENSINGTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15068-6426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
724-212-3345

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
408 8TH ST
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
NEW KENSINGTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15068-6426
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-980-1504
Provider Business Practice Location Address Fax Number:
724-212-3345
Provider Enumeration Date:
10/26/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GUNNER
Authorized Official First Name:
JAXIE
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
724-980-1504

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  CW016514 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 102458480-0001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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