1730320557 NPI number — MR. FREDERICK ELIAS PERSIKO M DIV., CACITI

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730320557 NPI number — MR. FREDERICK ELIAS PERSIKO M DIV., CACITI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERSIKO
Provider First Name:
FREDERICK
Provider Middle Name:
ELIAS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
M DIV., CACITI
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:
1730320557
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 138
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BASALT
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81621
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-927-5357
Provider Business Mailing Address Fax Number:
970-927-3467

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23400 TWO RIVERS ROAD
Provider Second Line Business Practice Location Address:
#49
Provider Business Practice Location Address City Name:
BASALT
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-927-5357
Provider Business Practice Location Address Fax Number:
970-927-3467
Provider Enumeration Date:
03/09/2009

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: 101YA0400X , with the licence number:  2810 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X , with the licence number: 6807010854 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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