1649316233 NPI number — DORIS PLUNKETT SANFORD

Table of content: DORIS PLUNKETT SANFORD (NPI 1649316233)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649316233 NPI number — DORIS PLUNKETT SANFORD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SANFORD
Provider First Name:
DORIS
Provider Middle Name:
PLUNKETT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1649316233
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22741 HIGHWAY 12
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39095-3118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-834-1721
Provider Business Mailing Address Fax Number:
662-834-1721

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 CARROLLTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39095-3250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-834-1721
Provider Business Practice Location Address Fax Number:
662-834-1721
Provider Enumeration Date:
01/30/2007

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: 363LF0000X , with the licence number:  R589101 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LG0600X , with the licence number: R589101 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 258908 . This is a "RHC PROVIDER NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: R589101 . This is a "RN LICENSE NUMBER" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 00117094 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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