Basic Information
| Provider Information | |||||||||
| NPI: | 1306131990 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CYSEWSKI | ||||||||
| FirstName: | JEFF | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3255 EXECUTIVE BLVD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777051051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883177720 | ||||||||
| FaxNumber: | 8773674187 | ||||||||
| Practice Location | |||||||||
| Address1: | 5959 SHALLOWFORD RD | ||||||||
| Address2: | SUITE 443 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374212285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237562268 | ||||||||
| FaxNumber: | 4232669690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2011 | ||||||||
| LastUpdateDate: | 06/13/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
No ID Information.