1891033072 NPI number — MISS MOLLY GEORGIANNE HANFORD MS TSSLD

Table of content: MISS MOLLY GEORGIANNE HANFORD MS TSSLD (NPI 1891033072)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891033072 NPI number — MISS MOLLY GEORGIANNE HANFORD MS TSSLD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HANFORD
Provider First Name:
MOLLY
Provider Middle Name:
GEORGIANNE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
MS TSSLD
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:
1891033072
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 41
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERTOWN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13601-0041
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-788-2730
Provider Business Mailing Address Fax Number:
315-788-8557

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 CENTER AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORIARTY
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87035
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-832-4471
Provider Business Practice Location Address Fax Number:
505-832-4472
Provider Enumeration Date:
01/23/2013

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: 235Z00000X , with the licence number:  5333 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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