1134311350 NPI number — PRUDENCE H MUNGER DC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134311350 NPI number — PRUDENCE H MUNGER DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUNGER
Provider First Name:
PRUDENCE
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
F

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:
1134311350
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2034 ALGONAC DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLINT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48532-4505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-280-6641
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
526 W GENESEE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRANKENMUTH
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48734-1357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-280-6641
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/12/2007

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: 111N00000X , with the licence number:  4219 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 2256 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 1814 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 5165 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: 2301006150 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 350 . This is a "MEDICARE RAILROAD PROVIDE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 35ZCDSH . This is a "MEDICARE PROVIDER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 1730111303 . This is a "CHIROPRACTIC" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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