1912177361 NPI number — MRS. ROSELLE YCU SOLIJON OTR

Table of content: JOHN RAY LAFFERTY (NPI 1982880589)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912177361 NPI number — MRS. ROSELLE YCU SOLIJON OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOLIJON
Provider First Name:
ROSELLE
Provider Middle Name:
YCU
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

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:
1912177361
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
206 MADISON ST
Provider Second Line Business Mailing Address:
APT. B
Provider Business Mailing Address City Name:
KENNETT
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63857-1735
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-559-5356
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 BARRETT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MALDEN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63863-1204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-276-3843
Provider Business Practice Location Address Fax Number:
573-276-5322
Provider Enumeration Date:
03/01/2008

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: 225X00000X , with the licence number:  2005010644 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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