1952482721 NPI number — ROADRUNNER OPTICAL CORP

Table of content: (NPI 1952482721)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952482721 NPI number — ROADRUNNER OPTICAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROADRUNNER OPTICAL CORP
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:
1952482721
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
377 N MONTEZUMA ST
Provider Second Line Business Mailing Address:
STE 108A
Provider Business Mailing Address City Name:
PRESCOTT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86301-3020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-445-3808
Provider Business Mailing Address Fax Number:
928-778-3559

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
377 N MONTEZUMA ST
Provider Second Line Business Practice Location Address:
STE 108A
Provider Business Practice Location Address City Name:
PRESCOTT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86301-3020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-445-3808
Provider Business Practice Location Address Fax Number:
928-778-3559
Provider Enumeration Date:
10/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BAKER
Authorized Official First Name:
HEIDI
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
928-445-3808

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  13-046129-A , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 14720 . This is a "SPECTERA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 43017 . This is a "DAVIS VISION" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0904090 . This is a "BLUE CROSS BLUE SHEILD OF" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 110664 . This is a "EYEMED" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 3813 . This is a "AVESIS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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