1053779421 NPI number — TERRI SQUIRES, LPC, FNP-C, PNP-C, APRN-RX

Table of content: (NPI 1053779421)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053779421 NPI number — TERRI SQUIRES, LPC, FNP-C, PNP-C, APRN-RX

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TERRI SQUIRES, LPC, FNP-C, PNP-C, APRN-RX
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:
6
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:
1053779421
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3629
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TELLURIDE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81435-3629
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-866-6533
Provider Business Mailing Address Fax Number:
888-338-7728

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
560 MOUNTAIN VILLAGE BLVD # 102A-B
Provider Second Line Business Practice Location Address:
SUITE 102A-B
Provider Business Practice Location Address City Name:
TELLURIDE
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81435-9513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-866-6533
Provider Business Practice Location Address Fax Number:
888-338-7728
Provider Enumeration Date:
02/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SQUIRES
Authorized Official First Name:
TERRI
Authorized Official Middle Name:
LEIGH
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
808-866-6533

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  5346 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 87485249 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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