1407805526 NPI number — LOLA FAYE HOUSTON N.P.

Table of content: LOLA FAYE HOUSTON N.P. (NPI 1407805526)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407805526 NPI number — LOLA FAYE HOUSTON N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOUSTON
Provider First Name:
LOLA
Provider Middle Name:
FAYE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
N.P.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HEWLETT
Provider Other First Name:
LOLA
Provider Other Middle Name:
FAYE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
N.P.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1407805526
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1305 N ELM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENDERSON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42420-2783
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-631-2412
Provider Business Mailing Address Fax Number:
270-827-7530

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
319 8TH ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42420-2963
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-827-5657
Provider Business Practice Location Address Fax Number:
270-827-8833
Provider Enumeration Date:
05/08/2006

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: 363LG0600X , with the licence number:  3002129 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 78001450 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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