1265879688 NPI number — MR. RICHARD A. LIESKE PT

Table of content: MR. RICHARD A. LIESKE PT (NPI 1265879688)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265879688 NPI number — MR. RICHARD A. LIESKE PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIESKE
Provider First Name:
RICHARD
Provider Middle Name:
A.
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

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:
1265879688
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
61 COMMERCE AVE SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-940-0660
Provider Business Mailing Address Fax Number:
616-940-1965

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26850 PROVIDENCE PKWY
Provider Second Line Business Practice Location Address:
SUITE 260
Provider Business Practice Location Address City Name:
NOVI
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48374
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-735-8272
Provider Business Practice Location Address Fax Number:
248-735-7276
Provider Enumeration Date:
05/24/2013

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: 2251X0800X , with the licence number:  5501008023 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 5501008023 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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