1518391176 NPI number — MR. SCOTT LANO DIVINAGRACIA PTA

Table of content: MR. SCOTT LANO DIVINAGRACIA PTA (NPI 1518391176)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518391176 NPI number — MR. SCOTT LANO DIVINAGRACIA PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIVINAGRACIA
Provider First Name:
SCOTT
Provider Middle Name:
LANO
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PTA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DIVINAGRACIA
Provider Other First Name:
SCOTT
Provider Other Middle Name:
LANO
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PTA
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1518391176
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5517 ALDERBROOK CT APT 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20851-2416
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-540-4602
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5215 W CEDAR LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BETHESDA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20814-1548
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-897-5500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2013

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: 314000000X , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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