1356978118 NPI number — VANDEVELDE MORENO AND ASSOCIATES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356978118 NPI number — VANDEVELDE MORENO AND ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VANDEVELDE MORENO AND ASSOCIATES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1356978118
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1089
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMEGA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31775-1089
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-392-5273
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 VIRGINIA AVE N STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TIFTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31794-4268
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-396-5507
Provider Business Practice Location Address Fax Number:
229-396-5093
Provider Enumeration Date:
03/23/2020

Additional Information

Authorized Official

Authorized Official Last Name:
VANDEVELDE MORENO
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
Authorized Official Title or Position:
MARRIAGE AND FAMILY THERAPIST
Authorized Official Telephone Number:
229-392-5273

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com