1386674620 NPI number — CLABEN REY M BARRACA M.D.

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 1386674620 NPI number — CLABEN REY M BARRACA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BARRACA
Provider First Name:
CLABEN
Provider Middle Name:
REY M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1386674620
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 INDEPENDENCE PT STE 212
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29615-4536
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-797-6307
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1033 EDGEFIELD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENWOOD
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29646-3205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-227-3908
Provider Business Practice Location Address Fax Number:
864-227-2668
Provider Enumeration Date:
07/03/2006

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: 2084P0800X , with the licence number:  20-26987 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: 26987 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 269872 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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