1982244737 NPI number — LONNIE JAY REARDON SUBMARINE IDC

Table of content: LONNIE JAY REARDON SUBMARINE IDC (NPI 1982244737)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982244737 NPI number — LONNIE JAY REARDON SUBMARINE IDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REARDON
Provider First Name:
LONNIE
Provider Middle Name:
JAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SUBMARINE IDC
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:
1982244737
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 SOUTH RD APT 12C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GROTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06340-4660
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 SOUTH RD APT 12C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GROTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06340-4660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
224-436-0181
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/09/2020

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: 1710I1002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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