1225261316 NPI number — LINDSAY ANN GARGOTTO PRACTICUM STUDENT

Table of content: LINDSAY ANN GARGOTTO PRACTICUM STUDENT (NPI 1225261316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225261316 NPI number — LINDSAY ANN GARGOTTO PRACTICUM STUDENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARGOTTO
Provider First Name:
LINDSAY
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PRACTICUM STUDENT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WORKS
Provider Other First Name:
LINDSAY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RADIOLOGICAL TECH
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1225261316
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2805 WAREHAM RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40242-2445
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-489-0956
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2805 WAREHAM RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40242-4024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-489-0956
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/24/2009

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: 390200000X , with the licence number:  603 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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