1467731430 NPI number — MS. LUCILLE AMELIA WHITAKER 11434

Table of content: MS. LUCILLE AMELIA WHITAKER 11434 (NPI 1467731430)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467731430 NPI number — MS. LUCILLE AMELIA WHITAKER 11434

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITAKER
Provider First Name:
LUCILLE
Provider Middle Name:
AMELIA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
11434
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:
1467731430
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
575 PRICE ST
Provider Second Line Business Mailing Address:
SUITE 313
Provider Business Mailing Address City Name:
PISMO BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93449-2553
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-201-9135
Provider Business Mailing Address Fax Number:
805-201-9134

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
575 PRICE ST
Provider Second Line Business Practice Location Address:
SUITE 313
Provider Business Practice Location Address City Name:
PISMO BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93449-2553
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-201-9135
Provider Business Practice Location Address Fax Number:
805-201-9134
Provider Enumeration Date:
08/09/2011

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: 363LF0000X , with the licence number:  348574 , 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)





Copyright © 2007-2025 www.npivalidator.com