1356542674 NPI number — ROSE HENDRICKSON PTA

Table of content: ROSE HENDRICKSON PTA (NPI 1356542674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356542674 NPI number — ROSE HENDRICKSON PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDRICKSON
Provider First Name:
ROSE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PTA
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:
1356542674
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3489 150TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52211-8622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-522-9444
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
616 BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRINNELL
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50112-2298
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-896-6400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/31/2007

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: 225200000X , with the licence number:  00743 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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