1952978736 NPI number — ENEDDY MARLENE CASTANEDA IBARRA

Table of content: ENEDDY MARLENE CASTANEDA IBARRA (NPI 1952978736)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952978736 NPI number — ENEDDY MARLENE CASTANEDA IBARRA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASTANEDA IBARRA
Provider First Name:
ENEDDY
Provider Middle Name:
MARLENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1952978736
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2330 PASEO DEL PRADO
Provider Second Line Business Mailing Address:
C 308
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89102-0076
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
725-600-7953
Provider Business Mailing Address Fax Number:
702-664-6933

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2330 PASEO DEL PRADO
Provider Second Line Business Practice Location Address:
C 308
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89102-0076
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
725-600-7953
Provider Business Practice Location Address Fax Number:
702-664-6933
Provider Enumeration Date:
06/09/2021

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: 3747P1801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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