1184675142 NPI number — MRS. MARCELLA BARBOUR FIACCO MS RD CDN

Table of content: MRS. MARCELLA BARBOUR FIACCO MS RD CDN (NPI 1184675142)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184675142 NPI number — MRS. MARCELLA BARBOUR FIACCO MS RD CDN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FIACCO
Provider First Name:
MARCELLA
Provider Middle Name:
BARBOUR
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS RD CDN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BARBOUR
Provider Other First Name:
JULIA
Provider Other Middle Name:
MARCELLA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184675142
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2536 FAWN RIDGE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CASTLETON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-479-1433
Provider Business Mailing Address Fax Number:
518-479-1433

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1523 COLUMBIA TURNPIKE
Provider Second Line Business Practice Location Address:
SERENITY DAY SPA
Provider Business Practice Location Address City Name:
CASTLETON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-479-1433
Provider Business Practice Location Address Fax Number:
518-479-1433
Provider Enumeration Date:
05/15/2006

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: 133V00000X , with the licence number:  0026991 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10106803 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 381226 . This is a "MVP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 8000017131 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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