1124079363 NPI number — MRS. CAROLYN FAITH CLAY-PINEDA P.T.

Table of content: MRS. CAROLYN FAITH CLAY-PINEDA P.T. (NPI 1124079363)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124079363 NPI number — MRS. CAROLYN FAITH CLAY-PINEDA P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLAY-PINEDA
Provider First Name:
CAROLYN
Provider Middle Name:
FAITH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLAY
Provider Other First Name:
CAROLYN
Provider Other Middle Name:
FAITH
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
P.T.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124079363
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/12/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
N1179 WPA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VULCAN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49892-8603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-563-9443
Provider Business Mailing Address Fax Number:
906-563-9443

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
W3101 RIDGECREST DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VULCAN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49892-8290
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-563-9443
Provider Business Practice Location Address Fax Number:
906-563-9443
Provider Enumeration Date:
05/12/2006

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: 208100000X , with the licence number:  5201004236 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X , with the licence number: 3472-026 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 650B21070-0 . This is a "BCBS GROUP PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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