1104955954 NPI number — MRS. ELLEN GROVER VINCENT LIC ACUP

Table of content: (NPI 1689672578)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104955954 NPI number — MRS. ELLEN GROVER VINCENT LIC ACUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VINCENT
Provider First Name:
ELLEN
Provider Middle Name:
GROVER
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LIC ACUP
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:
1104955954
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
328 W GODFREY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-276-1122
Provider Business Mailing Address Fax Number:
215-549-4007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
328 W GODFREY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-276-1122
Provider Business Practice Location Address Fax Number:
215-549-4007
Provider Enumeration Date:
03/05/2007

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: 171100000X , with the licence number:  AK000856 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com