1699915637 NPI number — MRS. ELISABETH VICTORIA RALEY LMT

Table of content: MRS. ELISABETH VICTORIA RALEY LMT (NPI 1699915637)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699915637 NPI number — MRS. ELISABETH VICTORIA RALEY LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RALEY
Provider First Name:
ELISABETH
Provider Middle Name:
VICTORIA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GONZALEZ
Provider Other First Name:
ELISABETH
Provider Other Middle Name:
VICTORIA
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1699915637
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 RIVERHILL CIR APT B3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29210-8131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-622-6569
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1531 AUGUSTA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29169-6128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-622-6569
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/04/2009

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: 225700000X , with the licence number:  4849 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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