1386771244 NPI number — MR. SHELOMOH JAMES THOMAS SOMAL JR. MSW

Table of content: (NPI 1184439325)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386771244 NPI number — MR. SHELOMOH JAMES THOMAS SOMAL JR. MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOMAL
Provider First Name:
SHELOMOH
Provider Middle Name:
JAMES THOMAS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
MSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SOMAL
Provider Other First Name:
SHELOMOH
Provider Other Middle Name:
ACHMED
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
JR.
Provider Other Credential Text:
MSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1386771244
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
07/17/2007
NPI Reactivation Date:
03/25/2019

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 SE MANLY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT SAINT LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34983
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-351-5192
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 SE MANLY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT SAINT LUCIE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34983
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-351-5192
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/27/2007

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: 104100000X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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