1023223880 NPI number — MR. DAVID ELVIN WICKHAM P.T.

Table of content: MR. DAVID ELVIN WICKHAM P.T. (NPI 1023223880)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023223880 NPI number — MR. DAVID ELVIN WICKHAM P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WICKHAM
Provider First Name:
DAVID
Provider Middle Name:
ELVIN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1023223880
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16330 TR 289
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONESVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-623-4069
Provider Business Mailing Address Fax Number:
740-623-4064

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
353 WALNUT ST
Provider Second Line Business Practice Location Address:
THREE RIVERS THERAPY SERVICES
Provider Business Practice Location Address City Name:
COSHOCTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43812-1531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-295-7080
Provider Business Practice Location Address Fax Number:
740-295-7081
Provider Enumeration Date:
05/14/2007

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:  5994 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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