1528402831 NPI number — LATOYA GREEN MHPP

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 1528402831 NPI number — LATOYA GREEN MHPP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
LATOYA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MHPP
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:
1528402831
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 S CHEROKEE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORRILTON
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72110-2656
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-354-4589
Provider Business Mailing Address Fax Number:
501-354-4510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
818 N CREEK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONWAY
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72032-4711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-327-9788
Provider Business Practice Location Address Fax Number:
501-327-9843
Provider Enumeration Date:
04/18/2013

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: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 196286795 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com