1366721904 NPI number — SUSAN DUBOSE

Table of content: ZACHARY WAYNE HICKS LCSW (NPI 1619246386)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366721904 NPI number — SUSAN DUBOSE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUSAN DUBOSE
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:
1366721904
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1436 S 6TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACCLENNY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32063-4623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-259-5868
Provider Business Mailing Address Fax Number:
904-259-5275

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1436 S 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MACCLENNY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32063-4623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-259-5868
Provider Business Practice Location Address Fax Number:
904-259-5275
Provider Enumeration Date:
08/14/2011

Additional Information

Authorized Official

Authorized Official Last Name:
WILKES
Authorized Official First Name:
LONNA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACIST
Authorized Official Telephone Number:
904-259-5868

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  EH11591 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 101160000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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