1346687373 NPI number — DR. LISA DARBONNE RACKLEY DDS

Table of content: DR. LISA DARBONNE RACKLEY DDS (NPI 1346687373)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346687373 NPI number — DR. LISA DARBONNE RACKLEY DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RACKLEY
Provider First Name:
LISA
Provider Middle Name:
DARBONNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

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:
1346687373
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
96TH MEDICAL GROUP
Provider Second Line Business Mailing Address:
307 BOATNER ROAD, STE 113
Provider Business Mailing Address City Name:
EGLIN AFB
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32542
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-883-9957
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
96TH MEDICAL GROUP
Provider Second Line Business Practice Location Address:
307 BOATNER ROAD
Provider Business Practice Location Address City Name:
EGLIN AFB
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-883-9957
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/31/2013

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: 1223G0001X , with the licence number:  3672 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 009247400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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