1508246331 NPI number — MALLARD CREEK LEARNING CENTER

Table of content: (NPI 1508246331)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508246331 NPI number — MALLARD CREEK LEARNING CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MALLARD CREEK LEARNING CENTER
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:
DIVINE HEALTH AND WELLNESS
Provider Other Organization Name Type Code:
3
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:
1508246331
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8136 BROWNE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28269-1101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-533-2870
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8136 BROWNE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28269-1101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-533-2870
Provider Business Practice Location Address Fax Number:
704-948-2047
Provider Enumeration Date:
06/06/2015

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
DENISE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
704-533-2870

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X , with the licence number: 60002874 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 252Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 60002874 . This is a "CHILD CARE LICENSE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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