1215277504 NPI number — RICKIE LYNN HERNANDEZ

Table of content: RICKIE LYNN HERNANDEZ (NPI 1215277504)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215277504 NPI number — RICKIE LYNN HERNANDEZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERNANDEZ
Provider First Name:
RICKIE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1215277504
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
48617 36TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BANGOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49013-9791
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-403-9430
Provider Business Mailing Address Fax Number:
269-427-7009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
48617 36TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BANGOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49013-9791
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-403-9430
Provider Business Practice Location Address Fax Number:
269-427-7009
Provider Enumeration Date:
02/22/2013

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: 171W00000X , with the licence number:  AF800328155 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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