1013258508 NPI number — ROBERT DAVE LAZARINE PT

Table of content: ROBERT DAVE LAZARINE PT (NPI 1013258508)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013258508 NPI number — ROBERT DAVE LAZARINE PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAZARINE
Provider First Name:
ROBERT
Provider Middle Name:
DAVE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1013258508
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
251 JOHNSTON ST SE
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35601-2515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-340-9708
Provider Business Mailing Address Fax Number:
256-340-9624

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30941 MILL LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPANISH FORT
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36527-5456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-625-2170
Provider Business Practice Location Address Fax Number:
251-625-2172
Provider Enumeration Date:
03/07/2013

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:  PTH7570 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 529917620 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1003819608 . This is a "GROUP NPI" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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