1407096928 NPI number — MS. DEBORAH LAVENNIA MILTON MM

Table of content: MS. DEBORAH LAVENNIA MILTON MM (NPI 1407096928)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407096928 NPI number — MS. DEBORAH LAVENNIA MILTON MM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILTON
Provider First Name:
DEBORAH
Provider Middle Name:
LAVENNIA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MM
Provider Gender Code:
F

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:
1407096928
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 DALE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROXBURY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02119-2274
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-543-2764
Provider Business Mailing Address Fax Number:
617-442-3825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
394 TRUMAN HIGHWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02186
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-543-4357
Provider Business Practice Location Address Fax Number:
617-364-1664
Provider Enumeration Date:
02/24/2009

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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