1962885657 NPI number — CELESTE CHEATHAM

Table of content: CELESTE CHEATHAM (NPI 1962885657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962885657 NPI number — CELESTE CHEATHAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHEATHAM
Provider First Name:
CELESTE
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:
1962885657
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5135 CAMINO AL NORTE
Provider Second Line Business Mailing Address:
STE 251
Provider Business Mailing Address City Name:
NORTH LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89031-2387
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-853-6719
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5135 CAMINO AL NORTE
Provider Second Line Business Practice Location Address:
STE 251
Provider Business Practice Location Address City Name:
NORTH LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89031-2387
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-853-6719
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/30/2015

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: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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