1861780652 NPI number — CLARA R SAM CT

Table of content: CLARA R SAM CT (NPI 1861780652)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861780652 NPI number — CLARA R SAM CT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SAM
Provider First Name:
CLARA
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CT
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:
1861780652
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 597
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOK
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99780-0597
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-324-2136
Provider Business Mailing Address Fax Number:
907-883-2136

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
TETLIN VILLAGE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TETLIN
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-324-2136
Provider Business Practice Location Address Fax Number:
907-324-2136
Provider Enumeration Date:
07/14/2011

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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