1700071263 NPI number —

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700071263 NPI number —

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

Provider First Name:

Provider Middle Name:

Provider Name Prefix Text:

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Provider Credential Text:

Provider Gender Code:

Provider Other Organization Name:

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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:

1700071263

Entity Type Code:

Replacement NPI:

Last Update Date:

NPI Deactivation Reason Code:

NPI Deactivation Date:

09/07/2012

NPI Reactivation Date:

Provider First Line Business Mailing Address:

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

Provider Business Mailing Address State Name:

Provider Business Mailing Address Postal Code:

Provider Business Mailing Address Country Code:

Provider Business Mailing Address Telephone Number:

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

Provider Business Practice Location Address State Name:

Provider Business Practice Location Address Postal Code:

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Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number: