1922672005 NPI number — ITS MINE MOVEMENT, INC

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 1922672005 NPI number — ITS MINE MOVEMENT, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ITS MINE MOVEMENT, 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:
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:
1922672005
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5693
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19129-0693
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
267-901-8612
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3662 CALUMET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19129-1750
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
267-879-0175
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/13/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
CAMILLA
Authorized Official Middle Name:
AMINAH
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
267-879-0175

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000 . This is a "NOT APPLICABLE" identifier . This identifiers is of the category "OTHER".