1538496252 NPI number — MR. MELVIN DEAN TIMBERLAKE LICDC

Table of content: MR. MELVIN DEAN TIMBERLAKE LICDC (NPI 1538496252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538496252 NPI number — MR. MELVIN DEAN TIMBERLAKE LICDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TIMBERLAKE
Provider First Name:
MELVIN
Provider Middle Name:
DEAN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LICDC
Provider Gender Code:
M

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:
1538496252
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
817 LABELLE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRILLIANT
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43913-1120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-381-3557
Provider Business Mailing Address Fax Number:
740-598-3956

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
817 LABELLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRILLIANT
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43913-1120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-381-3557
Provider Business Practice Location Address Fax Number:
740-598-3956
Provider Enumeration Date:
11/17/2009

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: 101YA0400X , with the licence number:  965747 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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