1043756711 NPI number — MR. CLARENCE D REPKA BS,AT,LAT

Table of content: MR. CLARENCE D REPKA BS,AT,LAT (NPI 1043756711)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043756711 NPI number — MR. CLARENCE D REPKA BS,AT,LAT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REPKA
Provider First Name:
CLARENCE
Provider Middle Name:
D
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
BS,AT,LAT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043756711
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
68 CAVALIER BLVD
Provider Second Line Business Mailing Address:
SUITE NUMBER 1700
Provider Business Mailing Address City Name:
FLORENCE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41042-1645
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-283-0707
Provider Business Mailing Address Fax Number:
859-647-3022

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
68 CAVALIER BLVD
Provider Second Line Business Practice Location Address:
SUITE NUMBER 1700
Provider Business Practice Location Address City Name:
FLORENCE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41042-1645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-283-0707
Provider Business Practice Location Address Fax Number:
859-647-3022
Provider Enumeration Date:
01/18/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  AT137 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2255A2300X , with the licence number: AT003583 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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