Basic Information
Provider Information
NPI: 1003001660
EntityType:  
ReplacementNPI:  
OrganizationName:  
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
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OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1:  
Address2:  
City:  
State:  
PostalCode:  
CountryCode:  
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1:  
Address2:  
City:  
State:  
PostalCode:  
CountryCode:  
TelephoneNumber:  
FaxNumber:  
Other Information
ProviderEnumerationDate:  
LastUpdateDate:  
NPIDeactivationReasonCode:  
NPIDeactivationDate: 05/27/2016
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor:  
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

No Taxonomy Information.

No ID Information.


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