1255680914 NPI number — MARIANO PRIME LIMITED LIABILITY

Table of content: (NPI 1255680914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255680914 NPI number — MARIANO PRIME LIMITED LIABILITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIANO PRIME LIMITED LIABILITY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1255680914
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2042 ARMY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEDEDO
Provider Business Mailing Address State Name:
GU
Provider Business Mailing Address Postal Code:
96929-6516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
671-646-5355
Provider Business Mailing Address Fax Number:
671-646-5333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2042 ARMY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEDEDO
Provider Business Practice Location Address State Name:
GU
Provider Business Practice Location Address Postal Code:
96929-6516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
671-646-5355
Provider Business Practice Location Address Fax Number:
671-646-5333
Provider Enumeration Date:
09/10/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MARIANO
Authorized Official First Name:
ARTHUR
Authorized Official Middle Name:
Authorized Official Title or Position:
R.PH. / PRESIDENT
Authorized Official Telephone Number:
671-646-5355

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PCY055 , registered in the state of GU ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2136841 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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