1033204300 NPI number — MISS DAISY'S GENTLEMEN OF THE FUTURE INC.

Table of content: (NPI 1033204300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033204300 NPI number — MISS DAISY'S GENTLEMEN OF THE FUTURE INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISS DAISY'S GENTLEMEN OF THE FUTURE INC.
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:
1033204300
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
304 FAIRVIEW AVE SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILSON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27893-4817
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-293-4683
Provider Business Mailing Address Fax Number:
252-291-6962

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
304 FAIRVIEW AVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILSON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27893-4817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-293-4683
Provider Business Practice Location Address Fax Number:
252-291-6962
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
TONYA
Authorized Official Middle Name:
FULLER
Authorized Official Title or Position:
DIRECTOR/QUALIFIED PROFESSIONAL
Authorized Official Telephone Number:
252-363-5446

Provider Taxonomy Codes

  • Taxonomy code: 320600000X , with the licence number:  MHL098100 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6603888 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com