1578564464 NPI number — JACQUELINE A RHEAULT OD

Table of content: JACQUELINE A RHEAULT OD (NPI 1578564464)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578564464 NPI number — JACQUELINE A RHEAULT OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RHEAULT
Provider First Name:
JACQUELINE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LIPSY
Provider Other First Name:
JACQUELINE
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578564464
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
248 PLEASANT ST
Provider Second Line Business Mailing Address:
STE 1600
Provider Business Mailing Address City Name:
CONCORD
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03301-2588
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-224-2020
Provider Business Mailing Address Fax Number:
603-228-0248

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
248 PLEASANT ST
Provider Second Line Business Practice Location Address:
STE 1600
Provider Business Practice Location Address City Name:
CONCORD
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03301-2588
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-224-2020
Provider Business Practice Location Address Fax Number:
603-228-0248
Provider Enumeration Date:
08/02/2005

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: 152W00000X , with the licence number:  0646 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 410038181 . This is a "MEDICARE RR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0900169YONH01 . This is a "ANTHEM" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 30010905 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 312992 . This is a "CIGNA" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".