1114544004 NPI number — ATLANTA DANIELLE ST.MARTIN RADT

Table of content: ATLANTA DANIELLE ST.MARTIN RADT (NPI 1114544004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114544004 NPI number — ATLANTA DANIELLE ST.MARTIN RADT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ST.MARTIN
Provider First Name:
ATLANTA
Provider Middle Name:
DANIELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RADT
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:
1114544004
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24566 ASHLAND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAGUNA HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92653-4332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-416-1095
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20331 FLANAGAN ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRABUCO CANYON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92679
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-582-8832
Provider Business Practice Location Address Fax Number:
818-582-8836
Provider Enumeration Date:
06/26/2020

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: 101YA0400X , with the licence number:  R1380090320 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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