1720316318 NPI number — INSTITUTE OF UROLOGY, LLC

Table of content: JESSICA LING CHEN DO (NPI 1194585083)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720316318 NPI number — INSTITUTE OF UROLOGY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INSTITUTE OF UROLOGY, LLC
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:
1720316318
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 33660
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAUGHLIN
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89028-3660
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-768-6800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5300 S HIGHWAY 95
Provider Second Line Business Practice Location Address:
SUITE K
Provider Business Practice Location Address City Name:
FORT MOHAVE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86426-9251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-768-6800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/19/2009

Additional Information

Authorized Official

Authorized Official Last Name:
TRABUCCO
Authorized Official First Name:
ARNALDO
Authorized Official Middle Name:
FRANCESCO
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
928-768-6800

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  42374 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 513717 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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