1962540583 NPI number — MS. DIANE GENCO MA

Table of content: MS. DIANE GENCO MA (NPI 1962540583)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962540583 NPI number — MS. DIANE GENCO MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GENCO
Provider First Name:
DIANE
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MA
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:
1962540583
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4205 N 7TH AVE
Provider Second Line Business Mailing Address:
#311
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85013-3078
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-253-8488
Provider Business Mailing Address Fax Number:
602-253-8340

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4205 N 7TH AVE
Provider Second Line Business Practice Location Address:
#311
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85013-3078
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-253-8488
Provider Business Practice Location Address Fax Number:
602-253-8340
Provider Enumeration Date:
02/03/2007

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 , with the licence number:  LPC 1330 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 880709 . This is a "AHCCCS NUMBER" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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