1063558864 NPI number — NEBCO ASSOCIATES, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063558864 NPI number — NEBCO ASSOCIATES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEBCO ASSOCIATES, INC.
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:
6
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:
1063558864
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16 HAWK RIDGE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE ST LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63367-1861
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-966-8377
Provider Business Mailing Address Fax Number:
480-736-9000

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3401 E ELWOOD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85040-1610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-296-6542
Provider Business Practice Location Address Fax Number:
602-437-2594
Provider Enumeration Date:
01/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MACIA
Authorized Official First Name:
ALAINA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
636-561-5686

Provider Taxonomy Codes

  • Taxonomy code: 347E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 174314 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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