1235590589 NPI number — MR. FRED N GANT LICENSED MARRIAGE AN

Table of content: MR. FRED N GANT LICENSED MARRIAGE AN (NPI 1235590589)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235590589 NPI number — MR. FRED N GANT LICENSED MARRIAGE AN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GANT
Provider First Name:
FRED
Provider Middle Name:
N
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LICENSED MARRIAGE AN
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:
1235590589
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18484 HIGHWAY 18
Provider Second Line Business Mailing Address:
UNIT # 125
Provider Business Mailing Address City Name:
APPLE VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-952-3454
Provider Business Mailing Address Fax Number:
866-247-9211

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18484 HIGHWAY 18
Provider Second Line Business Practice Location Address:
UNIT # 125
Provider Business Practice Location Address City Name:
APPLE VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-952-3454
Provider Business Practice Location Address Fax Number:
866-247-9211
Provider Enumeration Date:
03/15/2016

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: 106H00000X , with the licence number:  MFC40237 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com