1649580861 NPI number — MARTIN DE PORRES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649580861 NPI number — MARTIN DE PORRES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARTIN DE PORRES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1649580861
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
621 ELMONT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELMONT
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11003-4028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-502-2840
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
621 ELMONT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELMONT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11003-4028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-502-2840
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/21/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DANA
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF RELATED SERVICES
Authorized Official Telephone Number:
516-502-2840

Provider Taxonomy Codes

  • Taxonomy code: 1041S0200X , with the licence number:  6455725 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com