1417119223 NPI number — LAKEFRONT MEDICAL CENTER PA

Table of content: RACHEL MOORE GIBSON MS, RD, LDN (NPI 1588265268)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417119223 NPI number — LAKEFRONT MEDICAL CENTER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKEFRONT MEDICAL CENTER PA
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:
1417119223
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
60 W COLUMBIA ST
Provider Second Line Business Mailing Address:
SUITE F
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32806-1126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-841-0084
Provider Business Mailing Address Fax Number:
407-423-4406

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
60 W COLUMBIA ST
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32806-1126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-841-0084
Provider Business Practice Location Address Fax Number:
407-423-4406
Provider Enumeration Date:
07/02/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
VARRAUX
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PHYSICIAN/PRESIDENT
Authorized Official Telephone Number:
407-841-0084

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  ME0031947 , 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)