1194780080 NPI number — LADY OLGA'S LINGERIE

Table of content: (NPI 1194780080)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194780080 NPI number — LADY OLGA'S LINGERIE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LADY OLGA'S LINGERIE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1194780080
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3490 WHITNEY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMDEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06518-1936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-288-1133
Provider Business Mailing Address Fax Number:
203-288-6399

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3490 WHITNEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMDEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06518-1936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-288-1133
Provider Business Practice Location Address Fax Number:
203-288-6399
Provider Enumeration Date:
04/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FERGUSON
Authorized Official First Name:
JENIENE
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
203-288-1133

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0605442 . This is a "AETNA PROVIDER I.D." identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 1081160 . This is a "HMC/FOCUS PROVIDER I.D." identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: OR4663 . This is a "HEALTH NET PROVIDER I.D." identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 797849 . This is a "CONNECTICARE PROV. I.D." identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 12DME0544CT01 . This is a "ANTHEM BCBS PROV. I.D." identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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