1497994933 NPI number — ELIZABETH STACEY PECK R.D. L.D.

Table of content: ELIZABETH STACEY PECK R.D. L.D. (NPI 1497994933)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497994933 NPI number — ELIZABETH STACEY PECK R.D. L.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PECK
Provider First Name:
ELIZABETH
Provider Middle Name:
STACEY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
R.D. L.D.
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:
1497994933
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 DELAWARE ST SE
Provider Second Line Business Mailing Address:
MMC 84
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55455-0341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-273-5756
Provider Business Mailing Address Fax Number:
612-273-5039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 DELAWARE ST SE
Provider Second Line Business Practice Location Address:
MMC 84
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55455-0341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-273-5756
Provider Business Practice Location Address Fax Number:
612-273-5039
Provider Enumeration Date:
02/06/2009

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: 133V00000X , with the licence number:  2804 , 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)