1285071795 NPI number — MRS. ALICIA MICHELLE BIBEAU LDH

Table of content: MRS. ALICIA MICHELLE BIBEAU LDH (NPI 1285071795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285071795 NPI number — MRS. ALICIA MICHELLE BIBEAU LDH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BIBEAU
Provider First Name:
ALICIA
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LDH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BIBEAU
Provider Other First Name:
ALICIA
Provider Other Middle Name:
MICHELLE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
LDH
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1285071795
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1670 BEAM AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAPLEWOOD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55109-1201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-925-8400
Provider Business Mailing Address Fax Number:
651-925-8434

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1670 BEAM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAPLEWOOD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55109-1201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-925-8400
Provider Business Practice Location Address Fax Number:
651-925-8434
Provider Enumeration Date:
05/24/2013

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: 124Q00000X , with the licence number:  H8128 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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