1114305976 NPI number — PRACTICE WITHOUT PRESSURE PIKE CREEK

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 1114305976 NPI number — PRACTICE WITHOUT PRESSURE PIKE CREEK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRACTICE WITHOUT PRESSURE PIKE CREEK
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:
1114305976
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3105 LIMESTONE RD
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19808-2147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-635-7873
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3105 LIMESTONE RD
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19808-2147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-635-7873
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/13/2015

Additional Information

Authorized Official

Authorized Official Last Name:
THOMAS-GLAVIN
Authorized Official First Name:
HOPE
Authorized Official Middle Name:
DIANE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
302-635-7837

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  2015601326 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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