1689753501 NPI number — DIABETES CONCEPTS BY JAVINS, INC

Table of content: ALEXANDRA MY PHAM FNP (NPI 1598575128)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689753501 NPI number — DIABETES CONCEPTS BY JAVINS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIABETES CONCEPTS BY JAVINS, INC
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:
1689753501
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 ASSOCIATION DR
Provider Second Line Business Mailing Address:
SUITE 320, NORTH GATE BUSINESS PARK
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25311-1269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-344-3171
Provider Business Mailing Address Fax Number:
304-344-3178

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 ASSOCIATION DR
Provider Second Line Business Practice Location Address:
SUITE 320, NORTH GATE BUSINESS PARK
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25311-1269
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-344-3171
Provider Business Practice Location Address Fax Number:
304-344-3178
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JAVINS
Authorized Official First Name:
ELAINE
Authorized Official Middle Name:
JERRY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
304-344-3171

Provider Taxonomy Codes

  • Taxonomy code: 163WD0400X , with the licence number:  40454 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3810004840 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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