1790175107 NPI number — DR. MICHELLE MARIE MEDINA D.C.

Table of content: DR. MICHELLE MARIE MEDINA D.C. (NPI 1790175107)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790175107 NPI number — DR. MICHELLE MARIE MEDINA D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDINA
Provider First Name:
MICHELLE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MEDINA LUCIANO
Provider Other First Name:
MICHELLE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.C.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790175107
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 140226
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARECIBO
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00614-0226
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:
272 CALLE MARGINAL
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
HATILLO
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00659-2421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-544-5100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/23/2015

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: 111N00000X , with the licence number:  0529 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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