1578640074 NPI number — MISS PETAL CANDACE LEUWAISEE RDH

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578640074 NPI number — MISS PETAL CANDACE LEUWAISEE RDH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEUWAISEE
Provider First Name:
PETAL
Provider Middle Name:
CANDACE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
RDH
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:
1578640074
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
989 E 108TH ST
Provider Second Line Business Mailing Address:
SUITE 3C
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11236-3055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-649-0818
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
530 1ST AVE
Provider Second Line Business Practice Location Address:
SUITE9 QQ
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10016-6402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
121-299-8989
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/01/2006

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:  022881 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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