1366985178 NPI number — MISS MINERVA REFE BRIZUELA APN

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 1366985178 NPI number — MISS MINERVA REFE BRIZUELA APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRIZUELA
Provider First Name:
MINERVA
Provider Middle Name:
REFE
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:
1366985178
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
814 DELUCA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLEVILLE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07109-5351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-450-3083
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30-35 SO. HACKENSACK AVENUE
Provider Second Line Business Practice Location Address:
HUDSON COUNTY CORRECTIONAL
Provider Business Practice Location Address City Name:
KEARNY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-395-5600
Provider Business Practice Location Address Fax Number:
201-395-5618
Provider Enumeration Date:
11/28/2016

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: 363LA2200X , with the licence number:  26NN00511400 , 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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