1144209826 NPI number — MS. JINA VINCENT BRADFORD MCCANN

Table of content: MS. JINA VINCENT BRADFORD MCCANN (NPI 1144209826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144209826 NPI number — MS. JINA VINCENT BRADFORD MCCANN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCANN
Provider First Name:
JINA
Provider Middle Name:
VINCENT BRADFORD
Provider Name Prefix Text:
MS.
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:
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:
1144209826
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6348 LYNWOOD BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUND
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55364-1404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-901-6292
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8501 TANNER WILLIAMS RD
Provider Second Line Business Practice Location Address:
AVIATION TRAINING CENTER MOBILE
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36608-8322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-441-6725
Provider Business Practice Location Address Fax Number:
251-441-6415
Provider Enumeration Date:
01/11/2006

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: 247200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 27599 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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