1164638011 NPI number — FELISE DE NOVO, PC

Table of content: DR. SHAWN ANTHONY CLAVELL PT (NPI 1003353327)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164638011 NPI number — FELISE DE NOVO, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FELISE DE NOVO, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1164638011
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12851
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78212-2814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-419-3923
Provider Business Mailing Address Fax Number:
210-320-0958

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2400 MCCULLOUGH AVE
Provider Second Line Business Practice Location Address:
#12851
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78212-8001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-419-3923
Provider Business Practice Location Address Fax Number:
210-320-0958
Provider Enumeration Date:
05/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DE NOVO
Authorized Official First Name:
FELISE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
210-419-3923

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  16133 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1386723500 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0290504-02 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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