1578885919 NPI number — NAWANA MIESA GRAY OWNER/GENERAL MANAGE

Table of content: NAWANA MIESA GRAY OWNER/GENERAL MANAGE (NPI 1578885919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578885919 NPI number — NAWANA MIESA GRAY OWNER/GENERAL MANAGE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAY
Provider First Name:
NAWANA
Provider Middle Name:
MIESA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OWNER/GENERAL MANAGE
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:
1578885919
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 55311
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STOCKTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95205-8811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-594-9951
Provider Business Mailing Address Fax Number:
209-956-0443

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3007 GINKGO CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STOCKTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95212-2716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-594-9951
Provider Business Practice Location Address Fax Number:
209-956-0443
Provider Enumeration Date:
02/26/2010

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: 343900000X , with the licence number:  11-102997 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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