1619513496 NPI number — ALICIA RENEE COSTNER BCABA

Table of content: LEIDY CAROLINA VILLARRAGA (NPI 1457161853)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619513496 NPI number — ALICIA RENEE COSTNER BCABA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COSTNER
Provider First Name:
ALICIA
Provider Middle Name:
RENEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BCABA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
IDE
Provider Other First Name:
ALICIA
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1619513496
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13001 SEASCAPE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28278-7113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-877-3191
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1698 HWY 160 W.
Provider Second Line Business Practice Location Address:
STE. 240
Provider Business Practice Location Address City Name:
FORT MILL
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29708-2970
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-654-8599
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/27/2019

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: 103K00000X , with the licence number:  0-19-9516 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106E00000X , with the licence number: 0-19-9516 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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