1619712825 NPI number — SARETTA LANIECE GORDON-EDENBURGH

Table of content: SARETTA LANIECE GORDON-EDENBURGH (NPI 1619712825)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619712825 NPI number — SARETTA LANIECE GORDON-EDENBURGH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDON-EDENBURGH
Provider First Name:
SARETTA
Provider Middle Name:
LANIECE
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:
GORDON
Provider Other First Name:
SYREETA
Provider Other Middle Name:
LANIECE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1619712825
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1405 VILLA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH EUCLID
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44121-2903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-716-0242
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1405 VILLA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH EUCLID
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44121-2903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-716-0242
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/28/2024

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: 171W00000X , with the licence number:  SM696161 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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