1235439639 NPI number — GOVERNOR DIAGNOSTIC AND TREATMENT CENTER

Table of content: (NPI 1235439639)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235439639 NPI number — GOVERNOR DIAGNOSTIC AND TREATMENT CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOVERNOR DIAGNOSTIC AND TREATMENT CENTER
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:
1235439639
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
293 GOVERNOR ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVIDENCE
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02906-3220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-351-5730
Provider Business Mailing Address Fax Number:
401-331-6260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
293 GOVERNOR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROVIDENCE
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02906-3220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-351-5730
Provider Business Practice Location Address Fax Number:
401-331-6260
Provider Enumeration Date:
11/01/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MARWIL
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
TOBY
Authorized Official Title or Position:
SOLE PROPRIETOR
Authorized Official Telephone Number:
401-351-5730

Provider Taxonomy Codes

  • Taxonomy code: 2080P0006X , with the licence number:  5984 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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