1679541676 NPI number — MR. CLIFFORD LOREN MOUDY II I.D.C.

Table of content: MR. CLIFFORD LOREN MOUDY II I.D.C. (NPI 1679541676)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679541676 NPI number — MR. CLIFFORD LOREN MOUDY II I.D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOUDY
Provider First Name:
CLIFFORD
Provider Middle Name:
LOREN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
II
Provider Credential Text:
I.D.C.
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:
1679541676
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26800 104TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TREVOR
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53179-9619
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-688-2616
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3001A SIXTH ST
Provider Second Line Business Practice Location Address:
NAVAL HOSPITAL GREAT LAKES
Provider Business Practice Location Address City Name:
GREAT LAKES
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60088-5230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-688-2616
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/08/2006

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: 1710I1002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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