1336830082 NPI number —

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336830082 NPI number —

Employer Identification Number (EIN):

Provider Organization Name:

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NPI Number:

1336830082

Entity Type Code:

Replacement NPI:

Last Update Date:

NPI Deactivation Reason Code:

NPI Deactivation Date:

07/12/2025

NPI Reactivation Date:

Provider First Line Business Mailing Address:

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