1669280848 NPI number — MRS. LOVELY ROULETTE EDULLANTES UNABIA PT

Table of content: MRS. LOVELY ROULETTE EDULLANTES UNABIA PT (NPI 1669280848)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669280848 NPI number — MRS. LOVELY ROULETTE EDULLANTES UNABIA PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
UNABIA
Provider First Name:
LOVELY ROULETTE
Provider Middle Name:
EDULLANTES
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ABELLA
Provider Other First Name:
LOVELY ROULETTE
Provider Other Middle Name:
UNABIA
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1669280848
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1004 S DURKIN DR APT 11
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62704-1309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-801-7409
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
46 BROOKMEADE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RHINEBECK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12572-2317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-801-7409
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/20/2024

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: 225100000X , with the licence number:  053765 , 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)





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