1275697419 NPI number — VIVIETTE L. ALLEN

Table of content: VIVIETTE L. ALLEN (NPI 1275697419)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275697419 NPI number — VIVIETTE L. ALLEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALLEN
Provider First Name:
VIVIETTE
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1275697419
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1318 RAEFORD RD
Provider Second Line Business Mailing Address:
STE 1
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28305-5096
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-867-8889
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1540 PURDUE DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28303-5510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-867-8889
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/21/2006

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: 103T00000X , with the licence number:  1708 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X , with the licence number: COO1142 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 10588 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 6002468 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: MEDCOST . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 344141 . This is a "MHN TRICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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