1659702363 NPI number — AGNES TIMBERGER LISCENSED MASTER SOC

Table of content: AGNES TIMBERGER LISCENSED MASTER SOC (NPI 1659702363)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659702363 NPI number — AGNES TIMBERGER LISCENSED MASTER SOC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TIMBERGER
Provider First Name:
AGNES
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LISCENSED MASTER SOC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MONTALVO TIMBERGER
Provider Other First Name:
AGNES
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1659702363
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 330
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SLATE HILL
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10973-0330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-978-7979
Provider Business Mailing Address Fax Number:
845-355-7929

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
626 EATONTOWN ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT JERVIS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12771
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-978-7979
Provider Business Practice Location Address Fax Number:
845-355-7929
Provider Enumeration Date:
12/05/2013

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: 104100000X , with the licence number:  039221-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 089546-01 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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