1477249118 NPI number — STACY ANTONET RADCLIFFE PHLEBOTOMIST

Table of content: STACY ANTONET RADCLIFFE PHLEBOTOMIST (NPI 1477249118)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477249118 NPI number — STACY ANTONET RADCLIFFE PHLEBOTOMIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RADCLIFFE
Provider First Name:
STACY
Provider Middle Name:
ANTONET
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHLEBOTOMIST
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:
1477249118
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44489 TOWN CENTER WAY # 1022
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM DESERT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92260-2723
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-501-1890
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
73373 COUNTRY CLUB DR APT 2410
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM DESERT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92260-8648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-501-1890
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/14/2023

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: 246RP1900X , with the licence number:  CPT02015403 , 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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