1407555469 NPI number — NICOLE LORRAINE MATIAS-BADO

Table of content: NICOLE LORRAINE MATIAS-BADO (NPI 1407555469)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407555469 NPI number — NICOLE LORRAINE MATIAS-BADO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATIAS-BADO
Provider First Name:
NICOLE
Provider Middle Name:
LORRAINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1407555469
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 N 18TH ST APT 309
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23223-6394
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
939-242-9172
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1250 E MARSHALL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23298-5023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-828-9000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/28/2023

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: 163W00000X , with the licence number:  0001307440 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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