1013553957 NPI number — MANUEL AUGUSTO VALDEBRAN CANALES

Table of content: MANUEL AUGUSTO VALDEBRAN CANALES (NPI 1013553957)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013553957 NPI number — MANUEL AUGUSTO VALDEBRAN CANALES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VALDEBRAN CANALES
Provider First Name:
MANUEL
Provider Middle Name:
AUGUSTO
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:
1013553957
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 751461
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28275-1461
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-792-6200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5500 FRONT ST STE 440
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMMERVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29486-8137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-985-3565
Provider Business Practice Location Address Fax Number:
843-985-9389
Provider Enumeration Date:
11/26/2019

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: 207N00000X , with the licence number:  4383413 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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