1396403606 NPI number — TESA LENEE LUBANS DEHAVEN LM CPM

Table of content: TESA LENEE LUBANS DEHAVEN LM CPM (NPI 1396403606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396403606 NPI number — TESA LENEE LUBANS DEHAVEN LM CPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUBANS DEHAVEN
Provider First Name:
TESA
Provider Middle Name:
LENEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LM CPM
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:
1396403606
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 585
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOUGLAS CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96024-0585
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-845-0630
Provider Business Mailing Address Fax Number:
530-503-9803

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 TAYLOR STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEAVERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96093
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-845-0630
Provider Business Practice Location Address Fax Number:
530-503-9803
Provider Enumeration Date:
12/03/2021

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: 176B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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