1689702888 NPI number — BRENDA LOU LIVENGOOD

Table of content: BRENDA LOU LIVENGOOD (NPI 1689702888)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689702888 NPI number — BRENDA LOU LIVENGOOD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIVENGOOD
Provider First Name:
BRENDA
Provider Middle Name:
LOU
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:
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:
1689702888
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10955 N 79TH AVE LOT 99
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85345-5974
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-435-6203
Provider Business Mailing Address Fax Number:
623-435-6270

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6216 W GLENDALE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85301-2308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-435-6230
Provider Business Practice Location Address Fax Number:
623-435-6270
Provider Enumeration Date:
03/01/2007

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: 163WS0200X , with the licence number:  089041 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 920076 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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