1255472692 NPI number — CHERI LEIGH FAGAN OTRL

Table of content: CHERI LEIGH FAGAN OTRL (NPI 1255472692)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255472692 NPI number — CHERI LEIGH FAGAN OTRL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAGAN
Provider First Name:
CHERI
Provider Middle Name:
LEIGH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTRL
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WELLS
Provider Other First Name:
CHERI
Provider Other Middle Name:
LEIGH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTRL
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1255472692
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 384
Provider Second Line Business Mailing Address:
306 EAST 1ST ST
Provider Business Mailing Address City Name:
MIFFLINVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18631
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-752-4744
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
221 W TAMARACK ST
Provider Second Line Business Practice Location Address:
PINDAR PHYSICAL THERAPY INC
Provider Business Practice Location Address City Name:
HAZLETON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-401-6566
Provider Business Practice Location Address Fax Number:
570-501-2435
Provider Enumeration Date:
02/09/2007

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:  OC006277L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00298278 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com