Basic Information
Provider Information | |||||||||
NPI: | 1366738445 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LE | ||||||||
FirstName: | QUYCHI | ||||||||
MiddleName: | H | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3601 SW 160TH AVE STE 250 | ||||||||
Address2: |   | ||||||||
City: | MIRAMAR | ||||||||
State: | FL | ||||||||
PostalCode: | 330276314 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3058667123 | ||||||||
FaxNumber: | 8669844216 | ||||||||
Practice Location | |||||||||
Address1: | 930 NE DUNCAN RD | ||||||||
Address2: |   | ||||||||
City: | BLUE SPRINGS | ||||||||
State: | MO | ||||||||
PostalCode: | 640142173 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8162296677 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/27/2011 | ||||||||
LastUpdateDate: | 01/21/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/21/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 2016031237 | MO | Y |   | Allopathic & Osteopathic Physicians | General Practice |   |
ID Information
ID | Type | State | Issuer | Description | 2500037427 | 01 | MO | BNDD | OTHER | 1366738445 | 05 | MO |   | MEDICAID | 2016031237 | 01 | MO | MO STATE BOARD OF REGISTRATION FOR THE HEALING ARTS | OTHER |