1356932016 NPI number — ANDRE CONWAY IDC STUDENT

Table of content: ANDRE CONWAY IDC STUDENT (NPI 1356932016)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356932016 NPI number — ANDRE CONWAY IDC STUDENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONWAY
Provider First Name:
ANDRE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
IDC STUDENT
Provider Gender Code:
M

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:
1356932016
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
BUILDING 14, 34101 FARENHOLT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92134
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-532-9712
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
34101 FARENHOLT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92134-7000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-532-9712
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/26/2021

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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