1578548657 NPI number — LAURA WEINER GREENE OT

Table of content: LAURA WEINER GREENE OT (NPI 1578548657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578548657 NPI number — LAURA WEINER GREENE OT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREENE
Provider First Name:
LAURA
Provider Middle Name:
WEINER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OT
Provider Gender Code:
F

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:
1578548657
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
317 N EL CAMINO REAL
Provider Second Line Business Mailing Address:
STE 210
Provider Business Mailing Address City Name:
ENCINITAS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92024-2811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-634-0248
Provider Business Mailing Address Fax Number:
760-634-1782

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
317 N EL CAMINO REAL
Provider Second Line Business Practice Location Address:
#210
Provider Business Practice Location Address City Name:
ENCINITAS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92024-2811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-634-0248
Provider Business Practice Location Address Fax Number:
760-364-1782
Provider Enumeration Date:
12/12/2005

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: 225X00000X , with the licence number:  OT 1536 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: WOT1536A . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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