1053619627 NPI number — CARAVAGLIA CLINIC

Table of content: (NPI 1053619627)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053619627 NPI number — CARAVAGLIA CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARAVAGLIA CLINIC
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:
1053619627
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1230 TURTLE ROCK WAY
Provider Second Line Business Mailing Address:
APT 1B
Provider Business Mailing Address City Name:
HIGH POINT
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27265
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-816-1901
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1840 EASTCHESTER DRIVE
Provider Second Line Business Practice Location Address:
UNIT 106
Provider Business Practice Location Address City Name:
HIGH POINT
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-816-1901
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
CARAVAGLIA
Authorized Official First Name:
GINA
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
918-816-1901

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  4574 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X , with the licence number: 2011-01820 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200122600A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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