1336715705 NPI number — CAYLA MAE FLESHMAN PA

Table of content: CAYLA MAE FLESHMAN PA (NPI 1336715705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336715705 NPI number — CAYLA MAE FLESHMAN PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FLESHMAN
Provider First Name:
CAYLA
Provider Middle Name:
MAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SIMMONS
Provider Other First Name:
CAYLA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1336715705
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6069
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29171-6069
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-791-2000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
146 E HOSPITAL DR STE 550
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29169-4843
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-936-7410
Provider Business Practice Location Address Fax Number:
803-936-7412
Provider Enumeration Date:
05/27/2021

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: 363A00000X , with the licence number:  MPA.3950 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4786PA , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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