1699832113 NPI number — MR. MAYNARD VILLAVICENCIO UTAYDE PT

Table of content: MR. MAYNARD VILLAVICENCIO UTAYDE PT (NPI 1699832113)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699832113 NPI number — MR. MAYNARD VILLAVICENCIO UTAYDE PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
UTAYDE
Provider First Name:
MAYNARD
Provider Middle Name:
VILLAVICENCIO
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

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:
1699832113
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
51470 NORWICH DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRANGER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46530-8426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-257-9880
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1409 E DAY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MISHAWAKA
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46545-3671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-257-9880
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/03/2007

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: 225100000X , with the licence number:  05005198A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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