1720255847 NPI number — MR. EDRIAN J HAIRSTON MS ATC LAT

Table of content: MR. EDRIAN J HAIRSTON MS ATC LAT (NPI 1720255847)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720255847 NPI number — MR. EDRIAN J HAIRSTON MS ATC LAT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAIRSTON
Provider First Name:
EDRIAN
Provider Middle Name:
J
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MS ATC LAT
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:
1720255847
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 W SEMINOLE BLVD
Provider Second Line Business Mailing Address:
APT 150
Provider Business Mailing Address City Name:
SANFORD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32771-1200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-822-7166
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
STETSON UNIVERSITY 421 N WOODLAND BLVD
Provider Second Line Business Practice Location Address:
UNIT 8317
Provider Business Practice Location Address City Name:
DELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32723-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-822-7166
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/08/2008

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 , with the licence number:  AL 2455 , 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)





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