1275629339 NPI number — JON TODD BAUGHMAN PAC

Table of content: JON TODD BAUGHMAN PAC (NPI 1275629339)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275629339 NPI number — JON TODD BAUGHMAN PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAUGHMAN
Provider First Name:
JON
Provider Middle Name:
TODD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
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:
1275629339
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4363
Provider Second Line Business Mailing Address:
870 HERON DRIVE
Provider Business Mailing Address City Name:
PAGE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86040-4363
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-660-1337
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11495 CALLISON STREET
Provider Second Line Business Practice Location Address:
LIFE HOUSE COMMUNITY HEALTH CENTER
Provider Business Practice Location Address City Name:
SUTTON
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99674-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-631-7665
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/05/2006

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: 363A00000X , with the licence number:  PA20020040 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 442226 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".