1760550636 NPI number — 121ST CSH/BAACH

Table of content: (NPI 1760550636)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760550636 NPI number — 121ST CSH/BAACH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
121ST CSH/BAACH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1760550636
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
UNIT 15244 BOX 316
Provider Second Line Business Mailing Address:
ATTN UBO
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AP
Provider Business Mailing Address Postal Code:
96205-5244
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
01182279171858
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
UNIT 15244
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AP
Provider Business Practice Location Address Postal Code:
96205-5244
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
01182279171410
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCCUE
Authorized Official First Name:
CHONG
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF, UBO
Authorized Official Telephone Number:
01182279171857

Provider Taxonomy Codes

  • Taxonomy code: 261QM1100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2865M2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8210077 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".




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