1114202546 NPI number — RONALD REALES PT

Table of content: RONALD REALES PT (NPI 1114202546)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114202546 NPI number — RONALD REALES PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REALES
Provider First Name:
RONALD
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1114202546
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6616 N 160TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68116-4071
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-492-2662
Provider Business Mailing Address Fax Number:
402-492-2662

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 ELLIOTT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COUNCIL BLUFFS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51503-0239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-328-9500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/17/2011

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: 225100000X , with the licence number:  03052 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 1187 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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