1477721983 NPI number — MR. CHRISTOPHER THOMAS PENUEL PTA

Table of content: MR. CHRISTOPHER THOMAS PENUEL PTA (NPI 1477721983)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477721983 NPI number — MR. CHRISTOPHER THOMAS PENUEL PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENUEL
Provider First Name:
CHRISTOPHER
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PTA
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:
1477721983
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 PARIS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAYLORS
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29687-6958
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:
355 BERKMANS LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29605-5606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-235-9020
Provider Business Practice Location Address Fax Number:
864-235-9021
Provider Enumeration Date:
02/19/2008

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: 225200000X , with the licence number:  2209 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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