1114001393 NPI number — LESLIE MORALES OLIVER

Table of content: LESLIE MORALES OLIVER (NPI 1114001393)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114001393 NPI number — LESLIE MORALES OLIVER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORALES OLIVER
Provider First Name:
LESLIE
Provider Middle Name:
Provider Name Prefix Text:
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:
1114001393
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23 NORTH RD
Provider Second Line Business Mailing Address:
UNIT A-21
Provider Business Mailing Address City Name:
WAKEFIELD
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02879-2176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-789-0810
Provider Business Mailing Address Fax Number:
401-364-0099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23 NORTH RD
Provider Second Line Business Practice Location Address:
UNIT A-21
Provider Business Practice Location Address City Name:
WAKEFIELD
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02879-2176
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-789-0810
Provider Business Practice Location Address Fax Number:
401-364-0099
Provider Enumeration Date:
10/25/2006

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: 1041C0700X , with the licence number:  ISW00708 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 254058 . This is a "MAGELLAN HEALTH SERVICES" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 30667-2 . This is a "RI BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 406127 . This is a "BLUE CHIP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 050572443 . This is a "UNITED HEALTHCARE; AETNA" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 1027350 . This is a "NHPRI" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




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