1063557262 NPI number — MRS. STACEY ANN ECK PT, DPT

Table of content: MRS. STACEY ANN ECK PT, DPT (NPI 1063557262)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063557262 NPI number — MRS. STACEY ANN ECK PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ECK
Provider First Name:
STACEY
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HANSEN
Provider Other First Name:
STACEY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063557262
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5000 MEMORIAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TWO RIVERS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-794-5376
Provider Business Mailing Address Fax Number:
920-794-5472

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3821 DEWEY ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANIOWOC
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-682-7585
Provider Business Practice Location Address Fax Number:
920-686-3601
Provider Enumeration Date:
02/21/2007

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:  10686024 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 10686-24 , 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)

  • Identifier: 36144900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".