1992907794 NPI number — EDUARDO ALBERTO ENRIQUEZ P T PC

Table of content: EDUARDO ALBERTO ENRIQUEZ P T PC (NPI 1992907794)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992907794 NPI number — EDUARDO ALBERTO ENRIQUEZ P T PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ENRIQUEZ
Provider First Name:
EDUARDO
Provider Middle Name:
ALBERTO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P T PC
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:
1992907794
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5778 NEW MEADOW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YPSILANTI
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48197-7164
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-439-8410
Provider Business Mailing Address Fax Number:
734-439-8430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
905 DEXTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILAN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48160-1160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-439-8410
Provider Business Practice Location Address Fax Number:
734-439-8430
Provider Enumeration Date:
06/04/2007

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: 225100000X , with the licence number:  5501004167 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10425482410 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 383322512 . This is a "COMMERCIAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 650D657010 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com