1679552962 NPI number —

Table of content: (NPI 1679552962)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679552962 NPI number —

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1679552962
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
NPI Deactivation Reason Code:
NPI Deactivation Date:
12/04/2009
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
Provider Business Mailing Address State Name:
Provider Business Mailing Address Postal Code:
Provider Business Mailing Address Country Code:
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
Provider Business Practice Location Address State Name:
Provider Business Practice Location Address Postal Code:
Provider Business Practice Location Address Country Code:
Provider Business Practice Location Address Telephone Number:
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:

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

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