1366162059 NPI number — MR. TIMOTHY WAYNE MACKEY JR. IDC

Table of content: MR. TIMOTHY WAYNE MACKEY JR. IDC (NPI 1366162059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366162059 NPI number — MR. TIMOTHY WAYNE MACKEY JR. IDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACKEY
Provider First Name:
TIMOTHY
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
IDC
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:
1366162059
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34101 FARENHOLT AVE BLDG 14
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92134-5291
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-532-5110
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
USS ABRAHAM LINCOLN
Provider Second Line Business Practice Location Address:
CVN 72
Provider Business Practice Location Address City Name:
FPO
Provider Business Practice Location Address State Name:
AP
Provider Business Practice Location Address Postal Code:
96649
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-275-4040
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/01/2022

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1710I1002X , with the licence number: 1366162059 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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