1699007898 NPI number — MISS LESGREEN GAMMAD BABARAN PT

Table of content: MISS LESGREEN GAMMAD BABARAN PT (NPI 1699007898)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699007898 NPI number — MISS LESGREEN GAMMAD BABARAN PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BABARAN
Provider First Name:
LESGREEN
Provider Middle Name:
GAMMAD
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1699007898
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3201 W COMMERCIAL BLVD
Provider Second Line Business Mailing Address:
SUITE 116
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33309-3440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-886-8108
Provider Business Mailing Address Fax Number:
866-422-6431

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
650 E DEVON AVE
Provider Second Line Business Practice Location Address:
SUITE 190
Provider Business Practice Location Address City Name:
ITASCA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60143-1251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-379-8784
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/12/2010

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: 225100000X , with the licence number:  070.017468 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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