1720343825 NPI number — MISS CARROLL ANNETTE BEVERLY CADC-M

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720343825 NPI number — MISS CARROLL ANNETTE BEVERLY CADC-M

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEVERLY
Provider First Name:
CARROLL
Provider Middle Name:
ANNETTE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
CADC-M
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:
1720343825
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
445 S 4TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAGINAW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48601-2129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-752-6799
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3190 HALLMARK CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAGINAW
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48603-2190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-790-3366
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/05/2012

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: 101YA0400X , with the licence number:  B 164108067648 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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