1467920710 NPI number — MARIA LANA RUDD RRT

Table of content: JASON R GOODSPEED (NPI 1598088288)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467920710 NPI number — MARIA LANA RUDD RRT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUDD
Provider First Name:
MARIA
Provider Middle Name:
LANA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RRT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LING
Provider Other First Name:
MARIA
Provider Other Middle Name:
LANA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RRT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1467920710
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2122 E PEMBROKE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMPTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23664-1113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-271-7560
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2122 E PEMBROKE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMPTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23664-1113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-271-7560
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/05/2018

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: 227900000X , with the licence number:  0117005989 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2279E1000X , with the licence number: 0117005989 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2279H0200X , with the licence number: 0117005989 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2279P3800X , with the licence number: 0117005989 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BC3200X , with the licence number: 130956 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: 130956 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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