| NPI |
1356840896 |
The fax number associated with the location
address of the provider being identified. |
| Entity Type Code |
1 |
The date the provider was assigned a unique identifier (assigned an NPI). |
| Provider Last Name Legal Name |
BARLEY |
The date that a record was last updated or changed. |
| Provider First Name |
JUDY |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
| Provider Middle Name |
LEE |
The first name of the authorized official. |
| Provider Credential Text |
RADT1 |
The middle name of the authorized official. |
| Provider First Line Business Practice Location Address |
4343 WILLIAMSBOURGH DR |
The title or position of the authorized official. |
| Provider Business Practice Location Address City Name |
SACRAMENTO |
The 10-position telephone number of the authorized official. |
| Provider Business Practice Location Address State Name |
CA |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Provider Business Practice Location Address Postal Code |
958232006 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
| Provider Business Practice Location Address Country Code If outside U S |
US |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
| Provider Business Practice Location Address Telephone Number |
9163953552 |
|
| Provider Enumeration Date |
2/11/2018 |
|
| Last Update Date |
2/11/2018 |
|
| Provider Gender Code |
F |
|
| Healthcare Provider Taxonomy Code 1 |
101YA0400X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
| Is Sole Proprietor |
N |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |