1497941835 NPI number — MRS. CAROL MEHLBERG CARBERRY BA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497941835 NPI number — MRS. CAROL MEHLBERG CARBERRY BA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARBERRY
Provider First Name:
CAROL
Provider Middle Name:
MEHLBERG
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CARBERRY
Provider Other First Name:
CAROL
Provider Other Middle Name:
NOEL
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1497941835
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
745 GILDA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST AUGUSTINE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32086-7605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-794-7968
Provider Business Mailing Address Fax Number:
904-794-7968

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
745 GILDA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST AUGUSTINE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32086-7605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-794-7968
Provider Business Practice Location Address Fax Number:
904-794-7968
Provider Enumeration Date:
09/19/2007

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: 222Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 812228800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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