1922041300 NPI number — MS. COURTNEY ROSE DRISCOLL RD LDN

Table of content: MS. COURTNEY ROSE DRISCOLL RD LDN (NPI 1922041300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922041300 NPI number — MS. COURTNEY ROSE DRISCOLL RD LDN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DRISCOLL
Provider First Name:
COURTNEY
Provider Middle Name:
ROSE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RD LDN
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:
1922041300
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18 TERN ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH YARMOUTH
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
05664
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-364-3549
Provider Business Mailing Address Fax Number:
508-457-3977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26 WAMPUM DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BREWSTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-896-9080
Provider Business Practice Location Address Fax Number:
508-896-3399
Provider Enumeration Date:
06/14/2006

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: 133V00000X , with the licence number:  2422 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2422 . This is a "STATE LICENSE #" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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