1376045120 NPI number — MISS MACKENZIE GRACE WHITLEY LMT, CA

Table of content: MISS MACKENZIE GRACE WHITLEY LMT, CA (NPI 1376045120)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376045120 NPI number — MISS MACKENZIE GRACE WHITLEY LMT, CA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITLEY
Provider First Name:
MACKENZIE
Provider Middle Name:
GRACE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
LMT, CA
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:
1376045120
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
355 COLVER RD UNIT 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TALENT
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97540-9401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-941-5393
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 TALENT AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TALENT
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-941-5393
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/07/2018

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: 225700000X , with the licence number:  20079 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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