1174770663 NPI number — REBECCA GAYLE TOWNSEND SR. LPE

Table of content: REBECCA GAYLE TOWNSEND SR. LPE (NPI 1174770663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174770663 NPI number — REBECCA GAYLE TOWNSEND SR. LPE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TOWNSEND
Provider First Name:
REBECCA
Provider Middle Name:
GAYLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SR. LPE
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:
1174770663
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4008
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLARKSVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37043-0008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-551-4640
Provider Business Mailing Address Fax Number:
931-551-4641

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
116 N 2ND ST
Provider Second Line Business Practice Location Address:
SUITE B11
Provider Business Practice Location Address City Name:
CLARKSVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37040-3478
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-551-4640
Provider Business Practice Location Address Fax Number:
931-551-4641
Provider Enumeration Date:
08/26/2008

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: 103T00000X , with the licence number:  11632 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1520228 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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