1124364070 NPI number — ALICIA LYNNE IBANEZ P.A.

Table of content: ALICIA LYNNE IBANEZ P.A. (NPI 1124364070)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124364070 NPI number — ALICIA LYNNE IBANEZ P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IBANEZ
Provider First Name:
ALICIA
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.
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:
1124364070
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 CHANDELEUR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOORESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28117-5954
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-335-6122
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2131 AYRSLEY TOWN BLVD
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28273-3595
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
980-297-7733
Provider Business Practice Location Address Fax Number:
980-297-7744
Provider Enumeration Date:
12/21/2012

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: 363AM0700X , with the licence number:  0010-03995 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1570PA , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1124364070 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8103056 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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