1174796965 NPI number — MISS JACKLYN ARTATES BAGALAY P.T.

Table of content: MISS JACKLYN ARTATES BAGALAY P.T. (NPI 1174796965)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174796965 NPI number — MISS JACKLYN ARTATES BAGALAY P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAGALAY
Provider First Name:
JACKLYN
Provider Middle Name:
ARTATES
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1174796965
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3290 N RIDGE RD
Provider Second Line Business Mailing Address:
SUITE 290
Provider Business Mailing Address City Name:
ELLICOTT CITY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21043-3655
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-750-9006
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3290 N RIDGE RD
Provider Second Line Business Practice Location Address:
SUITE 290
Provider Business Practice Location Address City Name:
ELLICOTT CITY
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21043-3655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-750-9006
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/11/2008

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: 225100000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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