1821374893 NPI number — MRS. MELINDA MICHELLE SEGRAVES

Table of content: MRS. MELINDA MICHELLE SEGRAVES (NPI 1821374893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821374893 NPI number — MRS. MELINDA MICHELLE SEGRAVES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SEGRAVES
Provider First Name:
MELINDA
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
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:
1821374893
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
850 W IRONWOOD DR
Provider Second Line Business Mailing Address:
302
Provider Business Mailing Address City Name:
COEUR D ALENE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83814-4903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-868-8699
Provider Business Mailing Address Fax Number:
208-664-5228

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
850 W IRONWOOD DR
Provider Second Line Business Practice Location Address:
302
Provider Business Practice Location Address City Name:
COEUR D ALENE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83814-4903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-868-8699
Provider Business Practice Location Address Fax Number:
208-664-5228
Provider Enumeration Date:
10/22/2011

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: 225700000X , with the licence number:  MA60245136 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com