1487811246 NPI number — MR. TOM LANE III ATC

Table of content: MR. TOM LANE III ATC (NPI 1487811246)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487811246 NPI number — MR. TOM LANE III ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LANE
Provider First Name:
TOM
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
ATC
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:
1487811246
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1475 EDGEWOOD DRIVE
Provider Second Line Business Mailing Address:
APARTMENT 4B
Provider Business Mailing Address City Name:
LIMA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-302-1870
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1475 EDGEWOO DRIVE
Provider Second Line Business Practice Location Address:
APT 4B
Provider Business Practice Location Address City Name:
LIMA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-302-1870
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/20/2008

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: 2255A2300X , with the licence number:  AT-770 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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