1164496089 NPI number — STEPHEN DOUGLAS DEFRANC ATHLETIC TRAINER

Table of content: STEPHEN DOUGLAS DEFRANC ATHLETIC TRAINER (NPI 1164496089)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164496089 NPI number — STEPHEN DOUGLAS DEFRANC ATHLETIC TRAINER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEFRANC
Provider First Name:
STEPHEN
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ATHLETIC TRAINER
Provider Gender Code:
M

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:
1164496089
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:
20 SEAL COVE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLYMOUTH
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02360-2083
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-224-9199
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 ACADEMY DR
Provider Second Line Business Practice Location Address:
MASSACHUSETTS MARITIME ACADEMY
Provider Business Practice Location Address City Name:
BUZZARDS BAY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02532-3405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-337-7500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/15/2006

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: 174400000X , with the licence number:  1536 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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