1205875630 NPI number — EXPRESS MEDICAL INCORPORATED

Table of content: (NPI 1205875630)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205875630 NPI number — EXPRESS MEDICAL INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXPRESS MEDICAL INCORPORATED
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:
1205875630
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
312 W 9TH ST N
Provider Second Line Business Mailing Address:
STE 2
Provider Business Mailing Address City Name:
LADYSMITH
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54848-1270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-532-5154
Provider Business Mailing Address Fax Number:
715-532-5941

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
312 W 9TH ST N
Provider Second Line Business Practice Location Address:
STE 2
Provider Business Practice Location Address City Name:
LADYSMITH
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54848-1270
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-532-5154
Provider Business Practice Location Address Fax Number:
715-532-5941
Provider Enumeration Date:
06/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MIKUNDA
Authorized Official First Name:
ERIKA
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
715-532-5154

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 41665000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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