1720506868 NPI number — REBECCA LIGHT RDN, LD

Table of content: REBECCA LIGHT RDN, LD (NPI 1720506868)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720506868 NPI number — REBECCA LIGHT RDN, LD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIGHT
Provider First Name:
REBECCA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RDN, LD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRANTLEY
Provider Other First Name:
REBEECA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720506868
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2867
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36652-2867
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PO BOX 2867
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36652-2867
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-690-8158
Provider Business Practice Location Address Fax Number:
251-544-2149
Provider Enumeration Date:
09/08/2017

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: 133V00000X , with the licence number:  1940 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 630000013 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 011846 . This is a "MEDICARE PAYEE NUMBER" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 1063439065 . This is a "MAIN GROUP NPI PAYEE NUMBER" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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