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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: