1164653051 NPI number — TOM M. ATIMBO

Table of content: TOM M. ATIMBO (NPI 1164653051)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164653051 NPI number — TOM M. ATIMBO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ATIMBO
Provider First Name:
TOM
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1164653051
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
47 PALOMBA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06082-3868
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-253-5020
Provider Business Mailing Address Fax Number:
860-253-5030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2399 BOSTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILBRAHAM
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01095-1185
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-596-3111
Provider Business Practice Location Address Fax Number:
413-596-9072
Provider Enumeration Date:
07/27/2009

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: 101YM0800X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225200000X , with the licence number: 8468 , 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)