1275145526 NPI number — CHARLES BERNARD VON PRESLEY CHAPLAIN, STUDENT

Table of content: CHARLES BERNARD VON PRESLEY CHAPLAIN, STUDENT (NPI 1275145526)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275145526 NPI number — CHARLES BERNARD VON PRESLEY CHAPLAIN, STUDENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VON PRESLEY
Provider First Name:
CHARLES
Provider Middle Name:
BERNARD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CHAPLAIN, STUDENT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BARNES
Provider Other First Name:
CHARLES
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275145526
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2513 CATTLEMEN RD UNIT 2102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SARASOTA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34232-6293
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-486-2612
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6497 PARKLAND DR STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SARASOTA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34243-4097
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-486-2612
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/18/2020

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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