1720344690 NPI number — SANTA MARIA CLINIC

Table of content: SHERRY SUSAN CRUISE CSW (NPI 1396115515)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720344690 NPI number — SANTA MARIA CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANTA MARIA CLINIC
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:
1720344690
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
845 KEARNY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KEARNY
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07032-3244
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-991-1129
Provider Business Mailing Address Fax Number:
201-991-2272

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
845 KEARNY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KEARNY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07032-3244
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-991-1129
Provider Business Practice Location Address Fax Number:
201-991-2272
Provider Enumeration Date:
04/05/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SANCHEZ
Authorized Official First Name:
MAURICIO
Authorized Official Middle Name:
JORGE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
201-991-1129

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  25MA06334400 , 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)

  • Identifier: 235585 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".




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