1629423470 NPI number — MISS MELISSA LEE THOMAS M.ED RASAC II MARS

Table of content: MISS MELISSA LEE THOMAS M.ED RASAC II MARS (NPI 1629423470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629423470 NPI number — MISS MELISSA LEE THOMAS M.ED RASAC II MARS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMAS
Provider First Name:
MELISSA
Provider Middle Name:
LEE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
M.ED RASAC II MARS
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:
1629423470
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1513 JEFFERSON ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOONVILLE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-836-0076
Provider Business Mailing Address Fax Number:
573-449-8344

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1513 JEFFERSON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOONVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65233-2271
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-836-0076
Provider Business Practice Location Address Fax Number:
573-449-8344
Provider Enumeration Date:
04/29/2016

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: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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