1467569194 NPI number — KRISTINE MARIE BALSIMO MPT

Table of content: KRISTINE MARIE BALSIMO MPT (NPI 1467569194)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467569194 NPI number — KRISTINE MARIE BALSIMO MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALSIMO
Provider First Name:
KRISTINE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPT
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:
1467569194
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2632 ALAMO CIR NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLAINE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55449-5766
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-466-0170
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1935 CTY RD B2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55113-5766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-636-2666
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/25/2006

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: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7116 . This is a "LICENSE #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".