1104913623 NPI number — PREMIER PHYSICAL MEDICINE AND WELLNESS CLINIC

Table of content: AMANDA MARIE MCCARTER MHPP (NPI 1861641854)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104913623 NPI number — PREMIER PHYSICAL MEDICINE AND WELLNESS CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER PHYSICAL MEDICINE AND WELLNESS CLINIC
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:
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:
1104913623
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1550
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODRUFF
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54568-1550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-356-9999
Provider Business Mailing Address Fax Number:
715-356-9894

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1446 1ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODRUFF
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54568-9149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-356-9999
Provider Business Practice Location Address Fax Number:
715-356-9894
Provider Enumeration Date:
10/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MULLEN
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
715-356-9999

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  33657 , 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: 21307000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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