1255465464 NPI number — TERENCE MICHAEL DEVER

Table of content: TERENCE MICHAEL DEVER (NPI 1255465464)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255465464 NPI number — TERENCE MICHAEL DEVER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEVER
Provider First Name:
TERENCE
Provider Middle Name:
MICHAEL
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:
1255465464
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
164 LINCOLN ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN LUIS OBISPO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-781-3535
Provider Business Mailing Address Fax Number:
805-503-6499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3765 S. HIGUERA
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SAN LUIS OBISPO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-781-3535
Provider Business Practice Location Address Fax Number:
805-503-6499
Provider Enumeration Date:
03/16/2007

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

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

  • Identifier: 390200000X . This is a "TAXONOMY" identifier . This identifiers is of the category "OTHER".




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