1164432167 NPI number — MRS. STACY G PRESLEY OD

Table of content: MRS. STACY G PRESLEY OD (NPI 1164432167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164432167 NPI number — MRS. STACY G PRESLEY OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRESLEY
Provider First Name:
STACY
Provider Middle Name:
G
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OD
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:
1164432167
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1433 ARLINGTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ADA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74820-2636
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-332-5606
Provider Business Mailing Address Fax Number:
580-332-3946

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1433 ARLINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ADA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74820-2636
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-332-5606
Provider Business Practice Location Address Fax Number:
580-332-3946
Provider Enumeration Date:
08/09/2006

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: 152W00000X , with the licence number:  2431 , 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)

  • Identifier: 200078050A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201496058-001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com