1235217290 NPI number — MRS. LISA LONG HUDGENS MA

Table of content: MRS. LISA LONG HUDGENS MA (NPI 1235217290)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235217290 NPI number — MRS. LISA LONG HUDGENS MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HUDGENS
Provider First Name:
LISA
Provider Middle Name:
LONG
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA
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:
1235217290
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 GINN ALTMAN AVE STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMPTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29924-3963
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-943-2800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
NEW LIFE CENTER
Provider Second Line Business Practice Location Address:
102 GINN ALTMAN AVE, STE C
Provider Business Practice Location Address City Name:
HAMPTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-943-8175
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/01/2006

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: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 190166 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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