1114247277 NPI number — MRS. CAROL DALIRE CORPUZ

Table of content: MRS. CAROL DALIRE CORPUZ (NPI 1114247277)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114247277 NPI number — MRS. CAROL DALIRE CORPUZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORPUZ
Provider First Name:
CAROL
Provider Middle Name:
DALIRE
Provider Name Prefix Text:
MRS.
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:
DALIRE
Provider Other First Name:
CAROL
Provider Other Middle Name:
PAAT
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114247277
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-370-8206
Provider Business Mailing Address Fax Number:
517-435-3670

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
624 AVON PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAPOLEON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43545-1721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-736-1049
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/10/2010

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:  12675 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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