1033478219 NPI number — MR. KATHIRESAN RAJENDRAN M.S,CCC-SLP

Table of content: MR. KATHIRESAN RAJENDRAN M.S,CCC-SLP (NPI 1033478219)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033478219 NPI number — MR. KATHIRESAN RAJENDRAN M.S,CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAJENDRAN
Provider First Name:
KATHIRESAN
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M.S,CCC-SLP
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:
1033478219
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12627 SAN JOSE BLVD
Provider Second Line Business Mailing Address:
STE. 506
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32223-2662
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-300-0382
Provider Business Mailing Address Fax Number:
877-736-3470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12627 SAN JOSE BLVD
Provider Second Line Business Practice Location Address:
STE. 506
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32223-2662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-300-0382
Provider Business Practice Location Address Fax Number:
877-736-3470
Provider Enumeration Date:
05/09/2012

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: 235Z00000X , with the licence number:  SA10272 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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