1417233156 NPI number — RENEE A MATGOURANIS LD/RD

Table of content: RENEE A MATGOURANIS LD/RD (NPI 1417233156)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417233156 NPI number — RENEE A MATGOURANIS LD/RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATGOURANIS
Provider First Name:
RENEE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LD/RD
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:
1417233156
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31737 LEEWARD CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AVON LAKE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44012-2926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-933-2234
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3435 TROY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45504-4335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-342-8800
Provider Business Practice Location Address Fax Number:
937-342-8805
Provider Enumeration Date:
10/26/2011

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: 133V00000X , with the licence number:  2296 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 637662 . This is a "AMERICAN DIETITIC ASSOCIATION" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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