1750414611 NPI number — MRS. ELEANOR MAE REYNOLDS LPN

Table of content: MRS. ELEANOR MAE REYNOLDS LPN (NPI 1750414611)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750414611 NPI number — MRS. ELEANOR MAE REYNOLDS LPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REYNOLDS
Provider First Name:
ELEANOR
Provider Middle Name:
MAE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THOMPSON
Provider Other First Name:
ELEANOR
Provider Other Middle Name:
MAE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1750414611
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
246 MASON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAMPLAIN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12919-6202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-298-8554
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2739 RT 11
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOOERS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12958-2739
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-236-7241
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/13/2007

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: 164W00000X , with the licence number:  090251-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02755902 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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