1326170317 NPI number — GWENDOLYN LEE HALL CNM INC

Table of content: (NPI 1326170317)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326170317 NPI number — GWENDOLYN LEE HALL CNM INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GWENDOLYN LEE HALL CNM INC
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:
1326170317
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 617
Provider Second Line Business Mailing Address:
2947 HWY 260
Provider Business Mailing Address City Name:
OVERGAARD
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85933-0617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-535-4539
Provider Business Mailing Address Fax Number:
928-535-4895

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
261 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SNOWFLAKE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85937-5316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-536-5377
Provider Business Practice Location Address Fax Number:
928-536-5377
Provider Enumeration Date:
03/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HALL
Authorized Official First Name:
GWENDOLYN
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
928-535-4539

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  AP0244 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 490467 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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