1124212873 NPI number — JACY 2, LLC

Table of content: (NPI 1124212873)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124212873 NPI number — JACY 2, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACY 2, LLC
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:
WINGS
Provider Other Organization Name Type Code:
3
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:
1124212873
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1096 E 260TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW PRAGUE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56071-8880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-255-9530
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
319 CSAH #20
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITCHFIELD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-255-9530
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/05/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
CARMEN
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
320-255-9530

Provider Taxonomy Codes

  • Taxonomy code: 3245S0500X , with the licence number:  1047343 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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