1528386505 NPI number — MISS EMILY JASMINE HEAD LAC, MAOM

Table of content: MISS EMILY JASMINE HEAD LAC, MAOM (NPI 1528386505)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528386505 NPI number — MISS EMILY JASMINE HEAD LAC, MAOM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEAD
Provider First Name:
EMILY
Provider Middle Name:
JASMINE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
LAC, MAOM
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:
1528386505
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31360 HIGHWAY 20
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT BRAGG
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95437-9270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-969-7679
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
FORT BRAGG
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95437-3622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-969-7679
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/14/2010

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: 171100000X , with the licence number:  AC 13564 , 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