1992019541 NPI number — RACHAEL MULCH DPT

Table of content: RACHAEL MULCH DPT (NPI 1992019541)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992019541 NPI number — RACHAEL MULCH DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MULCH
Provider First Name:
RACHAEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BLOOM
Provider Other First Name:
RACHAEL
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1992019541
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
850 43RD AVE
Provider Second Line Business Mailing Address:
STE. 100
Provider Business Mailing Address City Name:
MOLINE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61265-8401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-743-2070
Provider Business Mailing Address Fax Number:
309-743-2073

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9901 N KNOXVILLE AVE
Provider Second Line Business Practice Location Address:
STE. D
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61615-1429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-243-1989
Provider Business Practice Location Address Fax Number:
309-243-8168
Provider Enumeration Date:
08/05/2010

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:  070017857 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 070-017857 . This is a "PT LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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