1326072919 NPI number — NETTIE D., LLC

Table of content: (NPI 1326072919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326072919 NPI number — NETTIE D., LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NETTIE D., LLC
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:
1326072919
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 27968
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84127-0968
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-966-8030
Provider Business Mailing Address Fax Number:
800-868-3117

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7118 GEOFFREY WAY
Provider Second Line Business Practice Location Address:
SUITE P
Provider Business Practice Location Address City Name:
FREDERICK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21704-7106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-874-3390
Provider Business Practice Location Address Fax Number:
301-694-9348
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MENCHEN
Authorized Official First Name:
ROBIN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
407-822-4600

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BX2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: 10200163 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4052471-00 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3810021092 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010108934 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1027810900002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036387100 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200043711 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".




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