1104988179 NPI number — MS. DIEM CHAU LAM NGUYEN MSW

Table of content: MS. DIEM CHAU LAM NGUYEN MSW (NPI 1104988179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104988179 NPI number — MS. DIEM CHAU LAM NGUYEN MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NGUYEN
Provider First Name:
DIEM CHAU
Provider Middle Name:
LAM
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSW
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:
1104988179
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:
102 MONTCLAIR AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
QUINCY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02171-2519
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-471-2057
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1353 DORCHESTER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DORCHESTER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02122-2932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-288-3230
Provider Business Practice Location Address Fax Number:
617-282-0954
Provider Enumeration Date:
12/15/2006

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: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0000000024333 . This is a "BMCHP HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: MPP089206 . This is a "LIABILITY INSURANCE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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