1760071096 NPI number — EXCLUSIVE ESTATES

Table of content: (NPI 1760071096)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760071096 NPI number — EXCLUSIVE ESTATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXCLUSIVE ESTATES
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:
1760071096
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1931 KINGSBURY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTGOMERY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36106-3409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-314-3868
Provider Business Mailing Address Fax Number:
334-398-8332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1931 KINGSBURY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTGOMERY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36106-3409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-314-3868
Provider Business Practice Location Address Fax Number:
334-398-8332
Provider Enumeration Date:
01/12/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FLOYD
Authorized Official First Name:
QUAVANTI
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
334-314-3868

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 202100000202 . This is a "OPEN" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".