1295167179 NPI number — MR. BENITO ARTILLERO ACHAS CDC1

Table of content: MR. BENITO ARTILLERO ACHAS CDC1 (NPI 1295167179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295167179 NPI number — MR. BENITO ARTILLERO ACHAS CDC1

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ACHAS
Provider First Name:
BENITO
Provider Middle Name:
ARTILLERO
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CDC1
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:
1295167179
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 KASHEVAROFF AVE APT 206
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KODIAK
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99615-6385
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-486-3172
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
717 E REZANOF DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KODIAK
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99615-6416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-481-2400
Provider Business Practice Location Address Fax Number:
907-481-2419
Provider Enumeration Date:
08/02/2013

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: 101YA0400X , with the licence number:  2266 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MH2237 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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