1750757720 NPI number — AUSBERTO J. GUERRA D.MIN.CDVC-IV

Table of content: AUSBERTO J. GUERRA D.MIN.CDVC-IV (NPI 1750757720)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750757720 NPI number — AUSBERTO J. GUERRA D.MIN.CDVC-IV

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUERRA
Provider First Name:
AUSBERTO
Provider Middle Name:
J.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.MIN.CDVC-IV
Provider Gender Code:
M

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:
1750757720
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
329 N GENESEE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAUKEGAN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60085-4205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-623-1730
Provider Business Mailing Address Fax Number:
847-623-1733

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
329 N GENESEE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUKEGAN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60085-4205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-623-1730
Provider Business Practice Location Address Fax Number:
847-623-1733
Provider Enumeration Date:
08/13/2015

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: 101Y00000X , with the licence number:  22305 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com