1548094311 NPI number — BANIBAJA CLHAVINZKY SILALAHI LAGUATAN

Table of content: BANIBAJA CLHAVINZKY SILALAHI LAGUATAN (NPI 1548094311)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548094311 NPI number — BANIBAJA CLHAVINZKY SILALAHI LAGUATAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAGUATAN
Provider First Name:
BANIBAJA
Provider Middle Name:
CLHAVINZKY SILALAHI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SILALAHI
Provider Other First Name:
BANIBAJA
Provider Other Middle Name:
CLHAVINZKY THERESIA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1548094311
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
328 GLEN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUMMERVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29483-4653
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1711 CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMMERVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29483-9320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-460-2605
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/26/2024

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: 106S00000X , with the licence number:  RBT-22-217639 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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