1972698090 NPI number — RACEBROOK SHOES LLC

Table of content: KENYON KENYATTA DIXON LPC (NPI 1124398789)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972698090 NPI number — RACEBROOK SHOES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RACEBROOK SHOES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1972698090
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
554 BOSTON POST RD
Provider Second Line Business Mailing Address:
SUITE 341
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06477-3341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-891-0772
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
554 BOSTON POST RD
Provider Second Line Business Practice Location Address:
SUITE 341
Provider Business Practice Location Address City Name:
ORANGE
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06477-3341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-891-0772
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SICSICO
Authorized Official First Name:
FRANK
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
203-891-0772

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004237154 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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