1689813545 NPI number — ST NICHOLAS HEALTH INSTITUTE SC

Table of content: (NPI 1689813545)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689813545 NPI number — ST NICHOLAS HEALTH INSTITUTE SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST NICHOLAS HEALTH INSTITUTE SC
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:
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:
1689813545
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1033 N MAYFAIR RD
Provider Second Line Business Mailing Address:
SUITE 303
Provider Business Mailing Address City Name:
WAUWATOSA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53226-3442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-778-1455
Provider Business Mailing Address Fax Number:
414-778-1865

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1033 N MAYFAIR RD
Provider Second Line Business Practice Location Address:
SUITE 303
Provider Business Practice Location Address City Name:
WAUWATOSA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53226-3442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-778-1455
Provider Business Practice Location Address Fax Number:
414-810-4052
Provider Enumeration Date:
02/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GOUNTIS
Authorized Official First Name:
BOB
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
414-778-1455

Provider Taxonomy Codes

  • Taxonomy code: 111NX0800X , with the licence number:  3517-012 , 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)





Copyright © 2007-2024 www.npivalidator.com