1871842427 NPI number — SAFIAH VAFAEIAN

Table of content: SAFIAH VAFAEIAN (NPI 1871842427)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871842427 NPI number — SAFIAH VAFAEIAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAFAEIAN
Provider First Name:
SAFIAH
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:
1871842427
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 WILMOT RD # 3113
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEERFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60015-4614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-925-4733
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
950 TOWNE LAKE PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODSTOCK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30189-1601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-925-4733
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/29/2012

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: 363LF0000X , with the licence number:  RN102635 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 093127745 , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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