1790162253 NPI number — MRS. GINA MARIE MADISON RD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790162253 NPI number — MRS. GINA MARIE MADISON RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MADISON
Provider First Name:
GINA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DOLENTI
Provider Other First Name:
GINA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790162253
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1515 EUBANK BLVD. SE BLDG. 831/832
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87185-1019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-844-4237
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1515 EUBANK BLVD SE BLDG. 831-832
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87185-1019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-844-4237
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/04/2015

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: 174H00000X , with the licence number:  1067342 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1067342 . This is a "REGISTERED DIETITIAN WITH COMMISSION ON DIETETIC REGISTRATION" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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