1710169339 NPI number — ALICIA DEMARTIN MSOM L.AC.

Table of content: ALICIA DEMARTIN MSOM L.AC. (NPI 1710169339)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710169339 NPI number — ALICIA DEMARTIN MSOM L.AC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEMARTIN
Provider First Name:
ALICIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSOM L.AC.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DEMARTIN
Provider Other First Name:
ALICIA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MIRES
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710169339
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 KIRTLAND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEEP RIVER
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06417-1817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-581-3286
Provider Business Mailing Address Fax Number:
860-767-7770

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1921 BOSTON POST RD STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTBROOK
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06498-2171
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-661-5824
Provider Business Practice Location Address Fax Number:
860-661-5843
Provider Enumeration Date:
12/05/2007

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: 171100000X , with the licence number:  0579 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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