1972639540 NPI number — ALICIA NOELLE QUINTANA MS OTRL

Table of content: ALICIA NOELLE QUINTANA MS OTRL (NPI 1972639540)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972639540 NPI number — ALICIA NOELLE QUINTANA MS OTRL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
QUINTANA
Provider First Name:
ALICIA
Provider Middle Name:
NOELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS OTRL
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:
1972639540
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:
8190 W DEER VALLEY RD
Provider Second Line Business Mailing Address:
SUITE 104-200
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85382-2126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-751-3672
Provider Business Mailing Address Fax Number:
623-572-6674

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8190 W DEER VALLEY RD
Provider Second Line Business Practice Location Address:
SUITE 104-200
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85382-2126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-751-3672
Provider Business Practice Location Address Fax Number:
623-572-6674
Provider Enumeration Date:
02/26/2007

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: 225XP0200X , with the licence number:  2595 , 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)





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