1548682339 NPI number — MRS. NICOLE L HANCOCK RD

Table of content: MRS. NICOLE L HANCOCK RD (NPI 1548682339)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548682339 NPI number — MRS. NICOLE L HANCOCK RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HANCOCK
Provider First Name:
NICOLE
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD
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:
1548682339
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1084 COUNTY ROAD 2630
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65560-7967
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-547-3373
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35629 HIGHWAY 72
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65560-7217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-729-5917
Provider Business Practice Location Address Fax Number:
573-729-5636
Provider Enumeration Date:
01/13/2014

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: 133V00000X , with the licence number:  2460 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133V00000X , with the licence number: 2010033235 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 350081231 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0957151 . This is a "CIGNA PID" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 26D0446923 . This is a "CLIA (TCMH)" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 003775591 . This is a "UHC MPIN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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