1720198435 NPI number — PETER A CONRIQUE

Table of content: PETER A CONRIQUE (NPI 1720198435)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720198435 NPI number — PETER A CONRIQUE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONRIQUE
Provider First Name:
PETER
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1720198435
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55801 BEAR RUN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CALLAHAN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32011-8514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-879-9576
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12961 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 201 & 202
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32218-2769
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-757-2474
Provider Business Practice Location Address Fax Number:
904-757-5541
Provider Enumeration Date:
08/30/2006

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: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT25868 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com