1013742659 NPI number — MRS. MICHELLE CARMENE DELICES LAC INTERN

Table of content: MRS. MICHELLE CARMENE DELICES LAC INTERN (NPI 1013742659)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013742659 NPI number — MRS. MICHELLE CARMENE DELICES LAC INTERN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DELICES
Provider First Name:
MICHELLE
Provider Middle Name:
CARMENE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LAC INTERN
Provider Gender Code:
F

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:
1013742659
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 BIRCH LN # 5C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06513-5705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
347-296-5355
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
99 WALLS ST N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
833-538-2735
Provider Business Practice Location Address Fax Number:
631-201-3212
Provider Enumeration Date:
09/04/2024

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: 101Y00000X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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