1407850985 NPI number — SOLSTAS LAB PARTNERS GROUP LLC

Table of content: MRS. LISA LEON L.C.S.W. (NPI 1750462453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407850985 NPI number — SOLSTAS LAB PARTNERS GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOLSTAS LAB PARTNERS GROUP 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:
1407850985
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1201 S COLLEGEVILLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLEGEVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19146-2998
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-454-6147
Provider Business Mailing Address Fax Number:
484-676-5309

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2906 JULIA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALDOSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31602-1435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-244-4468
Provider Business Practice Location Address Fax Number:
229-249-8191
Provider Enumeration Date:
06/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CONDE
Authorized Official First Name:
WILSON
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
800-227-0446

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  092002 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: L00065 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: L8165 . This is a "BLUE CROSS BLUE SHIELD FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 00057164A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 52183605 . This is a "BLUE CROSS BLUE SHIELD GA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 600-27858 . This is a "BLUE CROSS BLUE SHIELD AL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 030253800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 065023369 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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