1922285063 NPI number — LA SALETTE PERSONAL PRIMARY HEALTH CARE LLC

Table of content: (NPI 1922285063)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922285063 NPI number — LA SALETTE PERSONAL PRIMARY HEALTH CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LA SALETTE PERSONAL PRIMARY HEALTH CARE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MARGARITA M LASSALETTA DBA LA SALETTE PPHC
Provider Other Organization Name Type Code:
3
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:
1922285063
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
185 WADSWORTH RD
Provider Second Line Business Mailing Address:
2E
Provider Business Mailing Address City Name:
WADSWORTH
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44281-8330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-336-5046
Provider Business Mailing Address Fax Number:
330-336-5052

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
185 WADSWORTH RD
Provider Second Line Business Practice Location Address:
2E
Provider Business Practice Location Address City Name:
WADSWORTH
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44281-8330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-336-5046
Provider Business Practice Location Address Fax Number:
330-336-5052
Provider Enumeration Date:
01/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LASSALETTA
Authorized Official First Name:
MARGARITA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
330-336-5046

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  35067706L , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5908582 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 00000309393 . This is a "ABCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2045085 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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