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Deactivated
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NPI Number Detailed Information
Provider Information:
Name: | Deactivated |
Gender: | |
Provider License Number If Given: |
NPI Information:
NPI: | 1619970803 |
Entity Type (Individual or Organization): |
0-org |
Enumeration Date: | 1/0/1900 |
Last Update Date: | 1/0/1900 |
Provider Business Mailing Address:
Address: | , |
Phone Number: | |
Fax Number: |
Provider Business Practice Location Address:
Address: | , |
Phone Number: | |
Fax Number: |
Provider Taxonomy:
Primary: | 0 |
Secondary (if any): | |
State: |