1568121127 NPI number — CUMBERLAND RESIDENTIAL CARE, LLC

Table of content: MR. MIN SHICK AHN MD (NPI 1255326112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568121127 NPI number — CUMBERLAND RESIDENTIAL CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CUMBERLAND RESIDENTIAL CARE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1568121127
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2825 E COTTONWOOD PKWY STE 500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COTTONWOOD HEIGHTS
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84121-7060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-618-3784
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2825 EAST COTTONWOOD PARKWAY
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
COTTONWOOD HEIGHTS
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-618-3784
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/10/2021

Additional Information

Authorized Official

Authorized Official Last Name:
NDAYISEGA
Authorized Official First Name:
YANNICK
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
207-618-3784

Provider Taxonomy Codes

  • Taxonomy code: 323P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1790454486 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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