1144646837 NPI number — STUART BRANDON SPENCER JR. HAD

Table of content: STUART BRANDON SPENCER JR. HAD (NPI 1144646837)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144646837 NPI number — STUART BRANDON SPENCER JR. HAD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPENCER
Provider First Name:
STUART
Provider Middle Name:
BRANDON
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
HAD
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:
1144646837
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2510 E SUNSET RD
Provider Second Line Business Mailing Address:
UNIT 5-260
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89120-3511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-798-0113
Provider Business Mailing Address Fax Number:
866-291-5242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24310 MOULTON PKWY
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
LAGUNA WOODS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92637-3306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-830-5330
Provider Business Practice Location Address Fax Number:
949-830-6962
Provider Enumeration Date:
03/05/2014

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: 237700000X , with the licence number:  HA 7566 , 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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