1114127339 NPI number — CATHY ANNE GLASS

Table of content: CATHY ANNE GLASS (NPI 1114127339)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114127339 NPI number — CATHY ANNE GLASS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLASS
Provider First Name:
CATHY
Provider Middle Name:
ANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1114127339
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6721 COUNTY ROAD 248
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
O BRIEN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32071-4139
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-935-2263
Provider Business Mailing Address Fax Number:
386-935-2263

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6721 COUNTY ROAD 248
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
O BRIEN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32071-4139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-935-2263
Provider Business Practice Location Address Fax Number:
386-935-2263
Provider Enumeration Date:
07/25/2007

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: 222Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 811832900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com