1295789196 NPI number — GERALD L ECHOLS C.P.O.

Table of content: GERALD L ECHOLS C.P.O. (NPI 1295789196)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295789196 NPI number — GERALD L ECHOLS C.P.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ECHOLS
Provider First Name:
GERALD
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
C.P.O.
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:
1295789196
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1241 E. BROADWAY #28
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85204-2254
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-835-0909
Provider Business Mailing Address Fax Number:
480-835-6501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1241 E. BROADWAY #28
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85204-2254
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-835-0909
Provider Business Practice Location Address Fax Number:
480-835-6501
Provider Enumeration Date:
05/22/2006

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: 1744P3200X , with the licence number:  07-501426-Z , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: AZ-0274950 . This is a "BLUE CROSS BLUE SHIELD OF" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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