1861785156 NPI number — KAREN LEA BODDEN PT

Table of content: KAREN LEA BODDEN PT (NPI 1861785156)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861785156 NPI number — KAREN LEA BODDEN PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BODDEN
Provider First Name:
KAREN
Provider Middle Name:
LEA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SCHAUMBURG
Provider Other First Name:
KAREN
Provider Other Middle Name:
LEA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1861785156
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
360 S MOUNTIN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAYVILLE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53050-1498
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-387-7560
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
360 S MOUNTIN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAYVILLE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53050-1498
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-387-7560
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/19/2011

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: 225100000X , with the licence number:  5174-24 , 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)