1891808085 NPI number — LAKE PLEASANT INTERNAL MEDICINE PLC

Table of content: (NPI 1891808085)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891808085 NPI number — LAKE PLEASANT INTERNAL MEDICINE PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE PLEASANT INTERNAL MEDICINE PLC
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:
1891808085
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9059 W LAKE PLEASANT PKWY
Provider Second Line Business Mailing Address:
STE C-320
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85382-8336
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-455-3317
Provider Business Mailing Address Fax Number:
623-256-6551

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9059 W LAKE PLEASANT PKWY
Provider Second Line Business Practice Location Address:
STE C-320
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85382-8336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-455-3317
Provider Business Practice Location Address Fax Number:
623-256-6551
Provider Enumeration Date:
08/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHUA
Authorized Official First Name:
JOAN
Authorized Official Middle Name:
FRANCES
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
623-455-3317

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  31697 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 795974 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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