1659658748 NPI number — LARRY CHARLES SARGENT MA

Table of content: LARRY CHARLES SARGENT MA (NPI 1659658748)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659658748 NPI number — LARRY CHARLES SARGENT MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SARGENT
Provider First Name:
LARRY
Provider Middle Name:
CHARLES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SARGENT
Provider Other First Name:
LARRY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1659658748
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
167 PALENCIA VILLAGE DRIVE SUITE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST. AUGUSTINE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32095
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-224-5108
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
167 PALENCIA VILLAGE DR STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST AUGUSTINE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32095-8450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-224-5108
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/03/2011

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: 106H00000X , with the licence number:  IMT 1254 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: IMH 7278 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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