1003361742 NPI number — MR. CALEB JAMES HAYNIE SR. IDC

Table of content: MR. CALEB JAMES HAYNIE SR. IDC (NPI 1003361742)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003361742 NPI number — MR. CALEB JAMES HAYNIE SR. IDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAYNIE
Provider First Name:
CALEB
Provider Middle Name:
JAMES
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
SR.
Provider Credential Text:
IDC
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:
1003361742
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3423 GUADALCANAL RD BLDG 401 2ND DECK
Provider Second Line Business Mailing Address:
SEAL TEAM SEVENTEEN
Provider Business Mailing Address City Name:
CORONADO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92155-5599
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-537-1334
Provider Business Mailing Address Fax Number:
619-437-2068

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3423 GUADALCANAL RD BLDG 401 2ND DECK
Provider Second Line Business Practice Location Address:
SEAL TEAM SEVENTEEN
Provider Business Practice Location Address City Name:
CORONADO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92155-5599
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-537-1334
Provider Business Practice Location Address Fax Number:
619-437-2068
Provider Enumeration Date:
08/23/2016

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: 1710I1002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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