1356462527 NPI number — MICHELIN SORTOR CARROLL PT, ATC

Table of content: MICHELIN SORTOR CARROLL PT, ATC (NPI 1356462527)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356462527 NPI number — MICHELIN SORTOR CARROLL PT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARROLL
Provider First Name:
MICHELIN
Provider Middle Name:
SORTOR
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, ATC
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:
1356462527
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
277 BLAIR PARK ROAD
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
WILLISTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05495
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-878-3600
Provider Business Mailing Address Fax Number:
802-879-3041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
277 BLAIR PARK ROAD
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
WILLISTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05495
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-878-3600
Provider Business Practice Location Address Fax Number:
802-879-3041
Provider Enumeration Date:
04/03/2007

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: 225100000X , with the licence number:  040-0002722 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 040.0002722 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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