1891828786 NPI number — STANLEY HEALTH CLINICS PC

Table of content: (NPI 1891828786)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891828786 NPI number — STANLEY HEALTH CLINICS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STANLEY HEALTH CLINICS PC
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:
BACK AND NECK PAIN RELIEF CENTER OF WASILLA
Provider Other Organization Name Type Code:
3
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:
1891828786
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 W SWANSON AVE
Provider Second Line Business Mailing Address:
SUITE 109
Provider Business Mailing Address City Name:
WASILLA
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99654-6827
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-376-2600
Provider Business Mailing Address Fax Number:
907-376-2605

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 W SWANSON AVE
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
WASILLA
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99654-6827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-376-2600
Provider Business Practice Location Address Fax Number:
907-376-2605
Provider Enumeration Date:
03/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PAYNE
Authorized Official First Name:
TYAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
907-376-2600

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH0295 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 111N00000X , with the licence number: CH02971 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1992875777 . This is a "NPI" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".
  • Identifier: 1912072000 . This is a "NPI" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".




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