1275944175 NPI number — POETTKER PEDIATRIC THERAPY SERVICES, P.C

Table of content: (NPI 1275944175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275944175 NPI number — POETTKER PEDIATRIC THERAPY SERVICES, P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POETTKER PEDIATRIC THERAPY SERVICES, P.C
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:
1275944175
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14163 JEM DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AVISTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62216-3646
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-228-7229
Provider Business Mailing Address Fax Number:
618-228-7229

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14163 JEM DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AVISTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62216-3646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-228-7229
Provider Business Practice Location Address Fax Number:
618-228-7229
Provider Enumeration Date:
05/13/2014

Additional Information

Authorized Official

Authorized Official Last Name:
POETTKER
Authorized Official First Name:
NEELY
Authorized Official Middle Name:
REANNA
Authorized Official Title or Position:
OCCUPATIONAL THEARPIST
Authorized Official Telephone Number:
618-401-3210

Provider Taxonomy Codes

  • Taxonomy code: 225XP0200X , with the licence number:  2013002846 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com