1124220108 NPI number — SUZANNE E STACEY RD, LD

Table of content: SUZANNE E STACEY RD, LD (NPI 1124220108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124220108 NPI number — SUZANNE E STACEY RD, LD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STACEY
Provider First Name:
SUZANNE
Provider Middle Name:
E
Provider Name Prefix Text:
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:
1124220108
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3629 MCCLOUD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW PORT RICHEY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34655-2609
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-834-8199
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2040 SHORT AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
ODESSA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33556-3445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-372-9922
Provider Business Practice Location Address Fax Number:
727-372-8477
Provider Enumeration Date:
06/03/2007

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: 133V00000X , with the licence number:  ND4959 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com