1396834842 NPI number — MR. ROWLAND V BETTIES CADC III

Table of content: MR. ROWLAND V BETTIES CADC III (NPI 1396834842)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396834842 NPI number — MR. ROWLAND V BETTIES CADC III

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BETTIES
Provider First Name:
ROWLAND
Provider Middle Name:
V
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CADC III
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:
1396834842
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6400 INDUSTRIAL LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENDALE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53129-2452
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-423-4100
Provider Business Mailing Address Fax Number:
414-423-4134

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2801 N. 4TH STREET
Provider Second Line Business Practice Location Address:
SUITE 139
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53212-2711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-264-4217
Provider Business Practice Location Address Fax Number:
414-264-4218
Provider Enumeration Date:
10/12/2006

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: 101YA0400X , with the licence number:  14355 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 39172700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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