1376505503 NPI number — MR. PATRICK PAUL LA CROIX MPT

Table of content: MR. PATRICK PAUL LA CROIX MPT (NPI 1376505503)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376505503 NPI number — MR. PATRICK PAUL LA CROIX MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LA CROIX
Provider First Name:
PATRICK
Provider Middle Name:
PAUL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MPT
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:
1376505503
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:
223 S HORACE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODBURY
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08096-2286
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2103 BURLINGTON MOUNT HOLLY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08016-4157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-747-1915
Provider Business Practice Location Address Fax Number:
609-747-8565
Provider Enumeration Date:
04/04/2006

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: 225100000X , with the licence number:  QA00849600 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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