1023477916 NPI number — FOUR SEASONS MEDICAL SERVICES LLC

Table of content: KINYAM JUDE TEWELIKUM HHA (NPI 1841621950)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023477916 NPI number — FOUR SEASONS MEDICAL SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUR SEASONS MEDICAL SERVICES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1023477916
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2711 CENTERVILLE RD
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19808-1660
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-369-8112
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19820 N 7TH AVE
Provider Second Line Business Practice Location Address:
SUITE 230-D
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85027-4736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-369-8112
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/19/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MAXON MALDONADO
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
BRIAN
Authorized Official Title or Position:
MANAGER/PRESIDENT
Authorized Official Telephone Number:
602-369-8112

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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