1114029758 NPI number — MISS ANGELIA MARIE ARNOLD RD, LD

Table of content: MISS ANGELIA MARIE ARNOLD RD, LD (NPI 1114029758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114029758 NPI number — MISS ANGELIA MARIE ARNOLD RD, LD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ARNOLD
Provider First Name:
ANGELIA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
RD, LD
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:
1114029758
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
426 BLAKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OZARK
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36360-6218
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-796-1178
Provider Business Mailing Address Fax Number:
334-793-2404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1763 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOTHAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36301-3045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-793-3319
Provider Business Practice Location Address Fax Number:
334-793-2291
Provider Enumeration Date:
09/03/2006

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: 133VN1005X , with the licence number:  169ST , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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