1104201011 NPI number — DANA L VILLMORE PA

Table of content: DANA L VILLMORE PA (NPI 1104201011)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104201011 NPI number — DANA L VILLMORE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VILLMORE
Provider First Name:
DANA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

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:
1104201011
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 GANNETT DRIVE
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
SOUTH PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-828-0361
Provider Business Mailing Address Fax Number:
207-874-1483

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
INTERMED ONSITE AT IDEXX
Provider Second Line Business Practice Location Address:
1 IDEXX DRIVE
Provider Business Practice Location Address City Name:
WESTBROOK
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04092
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-556-6802
Provider Business Practice Location Address Fax Number:
207-556-4434
Provider Enumeration Date:
07/22/2015

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: 363A00000X , with the licence number:  PA1554 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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