1689261653 NPI number — CANDACE CHERILYN THOM-ROGERS MA, LAC

Table of content: CANDACE CHERILYN THOM-ROGERS MA, LAC (NPI 1689261653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689261653 NPI number — CANDACE CHERILYN THOM-ROGERS MA, LAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOM-ROGERS
Provider First Name:
CANDACE
Provider Middle Name:
CHERILYN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, LAC
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:
1689261653
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12 MAPLE AVE FL 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTCLAIR
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07042-4514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-732-8393
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 DUNNELL RD STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAPLEWOOD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07040-2634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-732-8393
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/24/2020

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: 101YM0800X , with the licence number:  37AC00554900 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com