1699086066 NPI number — SUZETTE ALENE MATHES COTA

Table of content: SUZETTE ALENE MATHES COTA (NPI 1699086066)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699086066 NPI number — SUZETTE ALENE MATHES COTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATHES
Provider First Name:
SUZETTE
Provider Middle Name:
ALENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
COTA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BEAN
Provider Other First Name:
SUZETTE
Provider Other Middle Name:
ALENE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1699086066
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12083 LENOVER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DILLSBORO
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-432-5226
Provider Business Mailing Address Fax Number:
812-432-5286

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12083 LENOVER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DILLSBORO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-432-5226
Provider Business Practice Location Address Fax Number:
812-432-5286
Provider Enumeration Date:
06/30/2010

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: 224Z00000X , with the licence number:  32000108A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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