1124004429 NPI number — MR. JOHN DANIEL STITHEM P.S. SCS

Table of content: MR. JOHN DANIEL STITHEM P.S. SCS (NPI 1124004429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124004429 NPI number — MR. JOHN DANIEL STITHEM P.S. SCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STITHEM
Provider First Name:
JOHN
Provider Middle Name:
DANIEL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.S. SCS
Provider Gender Code:
M

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:
1124004429
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
795 FARMERS LN
Provider Second Line Business Mailing Address:
SUTIE 10
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95405-6718
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-571-7615
Provider Business Mailing Address Fax Number:
707-571-8601

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
795 FARMERS LN
Provider Second Line Business Practice Location Address:
SUTIE 10
Provider Business Practice Location Address City Name:
SANTA ROSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95405-6718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-571-7615
Provider Business Practice Location Address Fax Number:
707-571-8601
Provider Enumeration Date:
12/19/2005

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: 2251X0800X , with the licence number:  PT12323 , 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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