1437159860 NPI number —

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437159860 NPI number —

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

Provider First Name:

Provider Middle Name:

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Provider Other Last Name Type Code:

NPI Number:

1437159860

Entity Type Code:

Replacement NPI:

Last Update Date:

NPI Deactivation Reason Code:

NPI Deactivation Date:

06/19/2018

NPI Reactivation Date:

Provider First Line Business Mailing Address:

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Provider Business Mailing Address City Name:

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Provider First Line Business Practice Location Address:

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Authorized Official Last Name:

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