1750415592 NPI number — DUSTY RAY BUFORD CATC - CAADE 040854

Table of content: DUSTY RAY BUFORD CATC - CAADE 040854 (NPI 1750415592)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750415592 NPI number — DUSTY RAY BUFORD CATC - CAADE 040854

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUFORD
Provider First Name:
DUSTY
Provider Middle Name:
RAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CATC - CAADE 040854
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:
1750415592
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1076 SANTO ANTONIO DR
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
COLTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92324-8103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-433-9824
Provider Business Mailing Address Fax Number:
909-433-9830

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1076 SANTO ANTONIO DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
COLTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92324-8103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-433-9824
Provider Business Practice Location Address Fax Number:
909-433-9830
Provider Enumeration Date:
03/15/2007

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: 101YA0400X , with the licence number:  040854 , 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)





Copyright © 2007-2024 www.npivalidator.com