1477640613 NPI number — FUNCTIONAL INTEGRATED THERAPY, LTD

Table of content: (NPI 1477640613)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477640613 NPI number — FUNCTIONAL INTEGRATED THERAPY, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FUNCTIONAL INTEGRATED THERAPY, LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FUNCTIONAL KIDS CLINIC
Provider Other Organization Name Type Code:
3
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:
1477640613
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2495 MAPLEWOOD DRIVE
Provider Second Line Business Mailing Address:
SUITE 313
Provider Business Mailing Address City Name:
MAPLEWOOD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55109-1913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-770-8884
Provider Business Mailing Address Fax Number:
651-770-8151

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2495 MAPLEWOOD DRIVE
Provider Second Line Business Practice Location Address:
SUITE 313
Provider Business Practice Location Address City Name:
MAPLEWOOD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55109-1913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-770-8884
Provider Business Practice Location Address Fax Number:
651-770-8151
Provider Enumeration Date:
10/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WORRELL
Authorized Official First Name:
KRISTI
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
OWNER/OPERATOR
Authorized Official Telephone Number:
651-770-8884

Provider Taxonomy Codes

  • Taxonomy code: 261QR0400X , with the licence number:  100591 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0007336046 . This is a "AETNA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 133343 . This is a "CHOICE PLUS/PATIENT CHOIC" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 28D39FU . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6401782 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 670043800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: J053 . This is a "UCARE GROUP" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 18905 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 181389 . This is a "UCARE INDIVIDUAL" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 36655 . This is a "ST PAUL ELECTRICAL WORKER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 75732 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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