1992846497 NPI number — JT BAGEN ENTERPRISES INC

Table of content: (NPI 1588471239)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992846497 NPI number — JT BAGEN ENTERPRISES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JT BAGEN ENTERPRISES INC
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:
6
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:
1992846497
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4721 TRANSIT ROAD
Provider Second Line Business Mailing Address:
SUITE 23
Provider Business Mailing Address City Name:
LANCASTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14043-3610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-706-5921
Provider Business Mailing Address Fax Number:
716-706-5923

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4721 TRANSIT ROAD
Provider Second Line Business Practice Location Address:
SUITE 23
Provider Business Practice Location Address City Name:
LANCASTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-706-5921
Provider Business Practice Location Address Fax Number:
716-706-5923
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BAGEN
Authorized Official First Name:
JENNY
Authorized Official Middle Name:
T
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
716-706-5921

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  F400997-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: BA1013 . This is a "OTHER PROVIDER MEDICARE IDENTIFIER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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