1871815472 NPI number — MARANDIA BADGER

Table of content: MARANDIA BADGER (NPI 1871815472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871815472 NPI number — MARANDIA BADGER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BADGER
Provider First Name:
MARANDIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1871815472
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4180 S PECOS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89121-5074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-685-1899
Provider Business Mailing Address Fax Number:
702-685-1799

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3304 CONTERRA PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89081-6537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-685-1899
Provider Business Practice Location Address Fax Number:
702-685-1799
Provider Enumeration Date:
02/23/2010

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GF-125401000-0015 . This is a "FACILITY NUMBER" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".




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