1588262174 NPI number — CANDY MILAGROS VENTURA STROMBERG

Table of content: CANDY MILAGROS VENTURA STROMBERG (NPI 1588262174)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588262174 NPI number — CANDY MILAGROS VENTURA STROMBERG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VENTURA STROMBERG
Provider First Name:
CANDY
Provider Middle Name:
MILAGROS
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:
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:
1588262174
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 BRANDYWINE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72227-5501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-779-6443
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1210 ALDERSGATE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72205-6606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-574-3053
Provider Business Practice Location Address Fax Number:
833-645-0881
Provider Enumeration Date:
10/15/2020

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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