NPI |
1942710918 |
Other last name by which the provider being identified is or has been known. |
Entity Type Code |
1 |
Other first name by which the provider being identified is or has been known (if an individual). This may be the same as the ‘‘Provider first name’’ if the provider is or has been known by a different last name only. |
Provider Last Name Legal Name |
ACEVEDO |
The other abbreviations for professional degrees or credentials used or held by the provider,
if the provider is an individual. Examples
are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations
will not be verified by NPS. |
Provider First Name |
DIANA |
The first name of the provider, if the provider
is an individual. |
Provider Middle Name |
ESTELA |
The middle name of the provider, if the provider
is an individual. |
Provider First Line Business Practice Location Address |
264 E HAVERHILL ST APT 16 |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Provider Business Practice Location Address City Name |
LAWRENCE |
The city name in the location address of the provider being identified. |
Provider Business Practice Location Address State Name |
MA |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address Postal Code |
018411455 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The telephone number associated with the location address of the provider being identified. |
Provider Business Practice Location Address Telephone Number |
9788936433 |
The fax number associated with the location
address of the provider being identified. |
Provider Enumeration Date |
10/4/2017 |
The date the provider was assigned a unique identifier (assigned an NPI). |
Last Update Date |
10/4/2017 |
The date that a record was last updated or changed. |
Provider Gender Code |
F |
The date that a record was last updated or changed. |
Healthcare Provider Taxonomy Code 1 |
101Y00000X |
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 |
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 Taxonomy Code 2 |
101YM0800X |
|
Healthcare Provider Primary Taxonomy Switch 2 |
N |
|
Healthcare Provider Taxonomy Code 3 |
103T00000X |
|
Healthcare Provider Primary Taxonomy Switch 3 |
N |
|
Healthcare Provider Taxonomy Code 4 |
104100000X |
|
Healthcare Provider Primary Taxonomy Switch 4 |
N |
|
Is Sole Proprietor |
Y |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
Healthcare Provider Taxonomy Group 1 |
193200000X MULTI-SPECIALTY GROUP |
|