1124801535 NPI number — CARL MICO ROJALES NATIVIDAD PT, CLT, CWS

Table of content: (NPI 1962493890)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124801535 NPI number — CARL MICO ROJALES NATIVIDAD PT, CLT, CWS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NATIVIDAD
Provider First Name:
CARL MICO
Provider Middle Name:
ROJALES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, CLT, CWS
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:
1124801535
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8995 SWAYING MEADOWS CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89178-6563
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
725-910-2884
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
640 W BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11561-2900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-431-4400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/17/2023

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:  044627-01 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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