1023375060 NPI number — AIMEE PATRICIA GALLAHORN CHAIII

Table of content: AIMEE PATRICIA GALLAHORN CHAIII (NPI 1023375060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023375060 NPI number — AIMEE PATRICIA GALLAHORN CHAIII

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GALLAHORN
Provider First Name:
AIMEE
Provider Middle Name:
PATRICIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CHAIII
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DAVENPORT
Provider Other First Name:
AIMEE
Provider Other Middle Name:
PATRICIA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CHAIII
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1023375060
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 49
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POINT HOPE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99766-0049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-368-2234
Provider Business Mailing Address Fax Number:
907-368-2569

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1749 QUALAGI AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POINT HOPE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-368-2234
Provider Business Practice Location Address Fax Number:
907-368-2569
Provider Enumeration Date:
04/16/2012

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: 172V00000X , with the licence number:  10-1055-III , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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