1982606752 NPI number — MARK L LEGNOLA D.C.

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 1982606752 NPI number — MARK L LEGNOLA D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEGNOLA
Provider First Name:
MARK
Provider Middle Name:
L
Provider Name Prefix Text:
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:
1982606752
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1717 SWEDE RD
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
BLUE BELL
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19422-3375
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
484-688-0664
Provider Business Mailing Address Fax Number:
484-688-0667

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1717 SWEDE RD
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
BLUE BELL
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19422-3375
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
484-688-0664
Provider Business Practice Location Address Fax Number:
484-688-0667
Provider Enumeration Date:
08/11/2005

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:  DC006991-L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2457323 . This is a "AETNA PIN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0395472000 . This is a "KEYSTONE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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