1124340880 NPI number — CHANNA LEE MORTON REGISTERED DIETICIAN

Table of content: CHANNA LEE MORTON REGISTERED DIETICIAN (NPI 1124340880)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124340880 NPI number — CHANNA LEE MORTON REGISTERED DIETICIAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORTON
Provider First Name:
CHANNA
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
REGISTERED DIETICIAN
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:
1124340880
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1498
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74355-1498
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-542-1655
Provider Business Mailing Address Fax Number:
918-540-1685

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7600 S HIGHWAY 69A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74354-1016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-542-1655
Provider Business Practice Location Address Fax Number:
918-540-1685
Provider Enumeration Date:
02/23/2010

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: 133V00000X , with the licence number:  871 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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