1992084867 NPI number — MICHELLE GALLARDO BANSAGAN ENCABO P.T.

Table of content: MICHELLE GALLARDO BANSAGAN ENCABO P.T. (NPI 1992084867)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992084867 NPI number — MICHELLE GALLARDO BANSAGAN ENCABO P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ENCABO
Provider First Name:
MICHELLE GALLARDO
Provider Middle Name:
BANSAGAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1992084867
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
408 POMPTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CEDAR GROVE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07009-1813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-433-0732
Provider Business Mailing Address Fax Number:
973-433-0733

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
902 N 5TH ST
Provider Second Line Business Practice Location Address:
UNIT C-103
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07107-4804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-732-4822
Provider Business Practice Location Address Fax Number:
973-732-4821
Provider Enumeration Date:
08/10/2011

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: 225100000X , with the licence number:  40QA01340100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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