1205006186 NPI number — DR. LETA A HICE MD

Table of content: DR. LETA A HICE MD (NPI 1205006186)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205006186 NPI number — DR. LETA A HICE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HICE
Provider First Name:
LETA
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOUSE
Provider Other First Name:
LETA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205006186
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2020 N CENTRAL AVE
Provider Second Line Business Mailing Address:
SUITE 1010
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85004-4501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-553-8400
Provider Business Mailing Address Fax Number:
602-553-8408

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2020 N CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE 1010
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85004-4501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-553-8400
Provider Business Practice Location Address Fax Number:
602-553-8408
Provider Enumeration Date:
03/06/2008

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: 390200000X , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 40380 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 336597 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".