1760435382 NPI number — CISCURA, INC

Table of content: (NPI 1760435382)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760435382 NPI number — CISCURA, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CISCURA, INC
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:
CISCURA INFUSION SERVICES
Provider Other Organization Name Type Code:
3
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:
1760435382
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
360 WINKLER DR
Provider Second Line Business Mailing Address:
SUITE F
Provider Business Mailing Address City Name:
ALPHARETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30004-0764
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-762-1520
Provider Business Mailing Address Fax Number:
678-762-1521

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
360 WINKLER DR
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
ALPHARETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30004-0764
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-762-1520
Provider Business Practice Location Address Fax Number:
678-762-1521
Provider Enumeration Date:
05/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KLEM
Authorized Official First Name:
ROLLYNE
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
678-762-1520

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 073277194A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 52212542-001 . This is a "BCBS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: DM1243 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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