1417584756 NPI number — ROBERT KENNETH WAYNE MITTON III

Table of content: ROBERT KENNETH WAYNE MITTON III (NPI 1417584756)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417584756 NPI number — ROBERT KENNETH WAYNE MITTON III

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MITTON
Provider First Name:
ROBERT
Provider Middle Name:
KENNETH WAYNE
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
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:
1417584756
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
421 FAYETTEVILLE ST STE 1100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27601-3000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-418-2978
Provider Business Mailing Address Fax Number:
866-500-2186

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
421 FAYETTEVILLE ST STE 1100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27601-3000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-418-2978
Provider Business Practice Location Address Fax Number:
866-500-2186
Provider Enumeration Date:
03/26/2020

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: 106S00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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