1124147806 NPI number — DR. JERRY A CARPENTER DC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124147806 NPI number — DR. JERRY A CARPENTER DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARPENTER
Provider First Name:
JERRY
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CARPENTER
Provider Other First Name:
J
Provider Other Middle Name:
C
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1124147806
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
910 KEHRS MILL RD
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
BALLWIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-391-1611
Provider Business Mailing Address Fax Number:
636-391-5856

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 KEHRS MILL RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
BALLWIN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-391-1611
Provider Business Practice Location Address Fax Number:
636-391-5856
Provider Enumeration Date:
03/27/2007

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: 111N00000X , with the licence number:  4902 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000408712 . This is a "BLUE CROSS GROUP PIN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 4648 . This is a "BLUE CROSS PIN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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