1336179795 NPI number — EATING DISORDERS, LLC

Table of content: (NPI 1336179795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336179795 NPI number — EATING DISORDERS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EATING DISORDERS, 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:
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:
1336179795
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
908 NIAGARA FALLS BLVD
Provider Second Line Business Mailing Address:
SUITE 208
Provider Business Mailing Address City Name:
NORTH TONAWANDA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14120-2019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-692-3302
Provider Business Mailing Address Fax Number:
716-692-4342

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2157 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUFFALO
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14214-2648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-862-1611
Provider Business Practice Location Address Fax Number:
716-692-4342
Provider Enumeration Date:
07/03/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DUKARM
Authorized Official First Name:
CAROLYN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
716-862-1611

Provider Taxonomy Codes

  • Taxonomy code: 2080A0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02527746 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".