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General NPI Number Information
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NPI Number | 1154138352
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Entity Type | Organization
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Legal Business Name | DEARIE PREVENTATIVE MEDICINE PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 12/12/2024
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Last Update Date | 02/25/2025
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Provider Practice Location Address
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Address Line | 418 BROADWAY STE N
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City | ALBANY
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State | NY
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Zip | 12207-2922
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Country | US
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Telephone | 206-486-2053
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 7241
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City | TACOMA
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State | WA
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Zip | 98417-0241
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Country | US
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Telephone | 206-486-2053
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | JENNIFER WHALEN
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Credential |
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Telephone | 217-737-3508
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2083P0901X
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Taxonomy Name | Public Health & General Preventive Medicine Physician
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License Number |
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License Number State |
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