1063704203 NPI number — NURSE PRACTITIONER ALLIANCE LLC

Table of content: (NPI 1063704203)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063704203 NPI number — NURSE PRACTITIONER ALLIANCE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NURSE PRACTITIONER ALLIANCE LLC
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:
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:
1063704203
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7326 STATE ROUTE 19 UNIT 5416
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT GILEAD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43338-9349
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-528-9333
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7326 STATE ROUTE 19
Provider Second Line Business Practice Location Address:
UNIT 5416
Provider Business Practice Location Address City Name:
MOUNT GILEAD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43338-9354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-528-9333
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/05/2011

Additional Information

Authorized Official

Authorized Official Last Name:
PIERCE
Authorized Official First Name:
DONNA
Authorized Official Middle Name:
FAY
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
419-528-9333

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  11665 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9395201 . This is a "MEDICARE PTAN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com