1669548244 NPI number — MRS. MARTHA M PECK CRNA

Table of content: MRS. MARTHA M PECK CRNA (NPI 1669548244)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669548244 NPI number — MRS. MARTHA M PECK CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PECK
Provider First Name:
MARTHA
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLEARY
Provider Other First Name:
MARTHA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1669548244
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 S MANCHESTER AVE STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92868-3219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-456-2986
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 THE CITY DR S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92868-3201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-880-7812
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/27/2006

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: 367500000X , with the licence number:  0024174791 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 3222 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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