1104553254 NPI number — HALEY PAIGE MATKINS GAINES DPT

Table of content: HALEY PAIGE MATKINS GAINES DPT (NPI 1104553254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104553254 NPI number — HALEY PAIGE MATKINS GAINES DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAINES
Provider First Name:
HALEY PAIGE
Provider Middle Name:
MATKINS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
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:
1104553254
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 CORPORATE DR STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOOVER
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35242-5424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-206-4158
Provider Business Mailing Address Fax Number:
717-773-4654

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
204 ENTERPRISE DR UNIT 15
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OXFORD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38655-2761
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-234-0010
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/08/2022

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: 225100000X , with the licence number:  PT7420 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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