1356092480 NPI number — MISS MADELINE KAYLIE DORESTIL APN

Table of content: MISS MADELINE KAYLIE DORESTIL APN (NPI 1356092480)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356092480 NPI number — MISS MADELINE KAYLIE DORESTIL APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DORESTIL
Provider First Name:
MADELINE
Provider Middle Name:
KAYLIE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
APN
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:
1356092480
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
234 GLOBE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UNION
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07083-7242
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
862-218-8245
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
126 US HIGHWAY 22
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07081-3175
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-381-0150
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/11/2022

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: 363LF0000X , with the licence number:  26NJ01239300 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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