1023446044 NPI number — MRS. SHIRLEY PEARL RELLER P.T.

Table of content: MRS. SHIRLEY PEARL RELLER P.T. (NPI 1023446044)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023446044 NPI number — MRS. SHIRLEY PEARL RELLER P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RELLER
Provider First Name:
SHIRLEY
Provider Middle Name:
PEARL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
YEE
Provider Other First Name:
SHIRLEY
Provider Other Middle Name:
PEARL
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1023446044
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCOBEY
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59263-0400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-487-2322
Provider Business Mailing Address Fax Number:
406-487-2325

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 5TH AVENUE EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SCOBEY
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59263-0400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-487-2322
Provider Business Practice Location Address Fax Number:
406-487-2325
Provider Enumeration Date:
10/30/2013

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:  PTP-PT-LIC-1011 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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