1104153691 NPI number — ELIZABETH MCEACHERN FARRELL DC

Table of content: ELIZABETH MCEACHERN FARRELL DC (NPI 1104153691)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104153691 NPI number — ELIZABETH MCEACHERN FARRELL DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FARRELL
Provider First Name:
ELIZABETH
Provider Middle Name:
MCEACHERN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STEVENSON
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
MCEACHERN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104153691
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 90256
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92169-2256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-410-0049
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4645 CASS ST
Provider Second Line Business Practice Location Address:
# 201C
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92109-2846
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-410-0049
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/04/2009

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: 111N00000X , with the licence number:  32488 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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