1699277004 NPI number — MRS. LEANN RENEE GASTELUM DIRECTOR

Table of content: MRS. LEANN RENEE GASTELUM DIRECTOR (NPI 1699277004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699277004 NPI number — MRS. LEANN RENEE GASTELUM DIRECTOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GASTELUM
Provider First Name:
LEANN
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DIRECTOR
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:
1699277004
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19301 WINTHROP ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48235
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-559-8224
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19301 WINTHROP ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48235
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-559-8224
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/01/2018

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: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3104A0625X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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