1922851047 NPI number — SAVANNAH DIMPNA SHORT INTERN MASTER'S LEVE

Table of content: SAVANNAH DIMPNA SHORT INTERN MASTER'S LEVE (NPI 1922851047)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922851047 NPI number — SAVANNAH DIMPNA SHORT INTERN MASTER'S LEVE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHORT
Provider First Name:
SAVANNAH
Provider Middle Name:
DIMPNA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
INTERN MASTER'S LEVE
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:
1922851047
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1214 ASPEN PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAVIS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95616-2036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-591-4668
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
628 MONTEZUMA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIO VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94571-1622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-374-5243
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/09/2024

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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