1689041907 NPI number — ANNABELL ROSS POTVIN N/A

Table of content: ANNABELL ROSS POTVIN N/A (NPI 1689041907)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689041907 NPI number — ANNABELL ROSS POTVIN N/A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POTVIN
Provider First Name:
ANNABELL
Provider Middle Name:
ROSS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
N/A
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:
1689041907
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3270 KERNER BLVD STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN RAFAEL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94901-4840
Provider Business Mailing Address Country Code:
US
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:
3270 KERNER BLVD
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
SAN RAFAEL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94901-4840
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-473-2100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/24/2015

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 390200000X . This is a "STUDENT IN AN ORGANIZED HEALTH CARE EDUCATION/TRAINING PROGRAM" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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