1609151489 NPI number — DONOVAN MAYCOCK NUTRITIONIST

Table of content: DONOVAN MAYCOCK NUTRITIONIST (NPI 1609151489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609151489 NPI number — DONOVAN MAYCOCK NUTRITIONIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAYCOCK
Provider First Name:
DONOVAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NUTRITIONIST
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:
1609151489
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16610 SAN PEDRO AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78232
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-778-4781
Provider Business Mailing Address Fax Number:
210-545-0444

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16610 SAN PEDRO AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-778-4781
Provider Business Practice Location Address Fax Number:
210-545-0444
Provider Enumeration Date:
10/12/2011

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: 133N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 133NN1002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 12138706 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 67752 . This is a "AMERICAN FITNESS PROFESSIONALS ASSOCIATION- CERTIFIED NUTRITION AND WELLNESS" identifier . This identifiers is of the category "OTHER".