1194839217 NPI number — JOHN C. LINCOLN LLC

Table of content: (NPI 1194839217)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194839217 NPI number — JOHN C. LINCOLN LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN C. LINCOLN LLC
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:
6
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:
1194839217
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9907
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85068-0907
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-249-2490
Provider Business Mailing Address Fax Number:
602-249-2555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9225 N 3RD ST
Provider Second Line Business Practice Location Address:
SUITE 307
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85020-2439
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-249-2490
Provider Business Practice Location Address Fax Number:
602-249-2555
Provider Enumeration Date:
08/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GROVER
Authorized Official First Name:
GARY
Authorized Official Middle Name:
Authorized Official Title or Position:
SR. VICE PRESIDENT
Authorized Official Telephone Number:
623-516-8637

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 830548 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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