1932967247 NPI number — MR. RICHARD TERRENCE LEE PUCKETT JR. N/A

Table of content: MR. RICHARD TERRENCE LEE PUCKETT JR. N/A (NPI 1932967247)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932967247 NPI number — MR. RICHARD TERRENCE LEE PUCKETT JR. N/A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PUCKETT
Provider First Name:
RICHARD
Provider Middle Name:
TERRENCE LEE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
N/A
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PUCKETT
Provider Other First Name:
LEE
Provider Other Middle Name:
TERRENCE
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
JR.
Provider Other Credential Text:
N/A
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1932967247
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 638
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DILLINGHAM
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99576-0638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-843-1191
Provider Business Mailing Address Fax Number:
--

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
533 CENTRAL AVENUE
Provider Second Line Business Practice Location Address:
638
Provider Business Practice Location Address City Name:
DILLINGHAM
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-843-1191
Provider Business Practice Location Address Fax Number:
--
Provider Enumeration Date:
03/11/2024

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: 101YA0400X , with the licence number:  101YA0400X , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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