1306127444 NPI number — NATHAN DURANT BLANTON LCAS

Table of content: NATHAN DURANT BLANTON LCAS (NPI 1306127444)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306127444 NPI number — NATHAN DURANT BLANTON LCAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLANTON
Provider First Name:
NATHAN
Provider Middle Name:
DURANT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCAS
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:
1306127444
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
60 COMMERCE PLZ
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEMBROKE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28372-7386
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-521-2900
Provider Business Mailing Address Fax Number:
910-775-9165

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
402 N PINE ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
LUMBERTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28358-5563
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-739-1666
Provider Business Practice Location Address Fax Number:
910-739-6822
Provider Enumeration Date:
09/02/2011

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 , with the licence number:  1844 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1844 . This is a "NORTH CAROLINA SUBSTANCE ABUSE PROFESSIONAL PRACTICE BOARD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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