1326439605 NPI number — DR. ARIEL PETRACCA SELK L.AC., DACM

Table of content: BRYAN VILLALTA (NPI 1770304404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326439605 NPI number — DR. ARIEL PETRACCA SELK L.AC., DACM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRACCA SELK
Provider First Name:
ARIEL
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
L.AC., DACM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PETRACCA
Provider Other First Name:
ARIEL
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
L.AC.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1326439605
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1608 WATERLOO AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH ST PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55075-1050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-321-5337
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14585 GRAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURNSVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55306-5719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-435-7349
Provider Business Practice Location Address Fax Number:
951-417-6159
Provider Enumeration Date:
02/09/2015

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: 171100000X , with the licence number:  1602 , 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)





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