1972897817 NPI number — DR. JOUBERT DESULME D.C,

Table of content: DR. JOUBERT DESULME D.C, (NPI 1972897817)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972897817 NPI number — DR. JOUBERT DESULME D.C,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DESULME
Provider First Name:
JOUBERT
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C,
Provider Gender Code:
M

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:
1972897817
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12000 4TH ST N
Provider Second Line Business Mailing Address:
APT 141
Provider Business Mailing Address City Name:
ST PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33716-1733
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-421-2139
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3775 CENTRAL AVE
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
ST PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33713-8338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-349-9432
Provider Business Practice Location Address Fax Number:
972-200-0485
Provider Enumeration Date:
06/08/2011

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: 111N00000X , with the licence number:  CH11533 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 11773 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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