1588919369 NPI number — MRS. LYAURO ALICIA VENEGAS JOHNSON

Table of content: MRS. LYAURO ALICIA VENEGAS JOHNSON (NPI 1588919369)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588919369 NPI number — MRS. LYAURO ALICIA VENEGAS JOHNSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VENEGAS JOHNSON
Provider First Name:
LYAURO
Provider Middle Name:
ALICIA
Provider Name Prefix Text:
MRS.
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:
1588919369
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
242 BARON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHELSEA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35043-6603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-515-9983
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIANA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35051-5359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-669-6713
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/18/2012

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: 183500000X , with the licence number:  11185 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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