1770857468 NPI number — SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS,P.C.

Table of content: YASMINE BOUMENIR RDN, CLC (NPI 1609576339)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770857468 NPI number — SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS,P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST LUNG & CRITICAL CARE SPECIALISTS,P.C.
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:
SOUTHEAST LUNG ASSOCIATES
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:
1770857468
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
340 HODGSON CT
Provider Second Line Business Mailing Address:
SUITE #2
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31406-1520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-629-2290
Provider Business Mailing Address Fax Number:
912-629-2291

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 COLONIAL WAY
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
JESUP
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31545-0130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-629-2290
Provider Business Practice Location Address Fax Number:
912-629-2291
Provider Enumeration Date:
02/28/2012

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNG
Authorized Official First Name:
APRIL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
912-629-0457

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000473833F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000526336A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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