1972035335 NPI number — MR. RJAI DE RICO GARDNER BA CSS

Table of content: MR. RJAI DE RICO GARDNER BA CSS (NPI 1972035335)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972035335 NPI number — MR. RJAI DE RICO GARDNER BA CSS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARDNER
Provider First Name:
RJAI
Provider Middle Name:
DE RICO
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
BA CSS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GARDNER
Provider Other First Name:
RJAI
Provider Other Middle Name:
DE RICO
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
BA CSS
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1972035335
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
428 24TH AVE N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39705-1945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-241-7097
Provider Business Mailing Address Fax Number:
662-245-0511

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
428 24TH AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39705-1945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-241-7097
Provider Business Practice Location Address Fax Number:
662-245-0511
Provider Enumeration Date:
04/03/2017

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com