1467589697 NPI number — VERA MARIE LEISURE MFTI

Table of content: VERA MARIE LEISURE MFTI (NPI 1467589697)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467589697 NPI number — VERA MARIE LEISURE MFTI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEISURE
Provider First Name:
VERA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MFTI
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:
1467589697
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
398 D ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RAMONA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92065-2463
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-788-9724
Provider Business Mailing Address Fax Number:
760-788-9754

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
398 D ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RAMONA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92065-2463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-788-9724
Provider Business Practice Location Address Fax Number:
760-788-9754
Provider Enumeration Date:
02/27/2007

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: 106H00000X , with the licence number:  IMF 47388 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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