1972623742 NPI number — MRS. CARNEICE LATRELL BOWERS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972623742 NPI number — MRS. CARNEICE LATRELL BOWERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOWERS
Provider First Name:
CARNEICE
Provider Middle Name:
LATRELL
Provider Name Prefix Text:
MRS.
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:
LONDON
Provider Other First Name:
CARNEICE
Provider Other Middle Name:
LATRELLL
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1972623742
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2163
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHIEFLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32644
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-490-8122
Provider Business Mailing Address Fax Number:
352-490-7711

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2202 N YOUNG BLVD
Provider Second Line Business Practice Location Address:
#300
Provider Business Practice Location Address City Name:
CHIEFLAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-493-7447
Provider Business Practice Location Address Fax Number:
352-490-7711
Provider Enumeration Date:
03/29/2007

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: 183700000X , with the licence number:  2401010215576 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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