1437217643 NPI number — LYNN E FLINT WIDDIFIELD

Table of content: (NPI 1437217643)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437217643 NPI number — LYNN E FLINT WIDDIFIELD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LYNN E FLINT WIDDIFIELD
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:
1437217643
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1811 W 2ND ST
Provider Second Line Business Mailing Address:
SUITE 310
Provider Business Mailing Address City Name:
GRAND ISLAND
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68803-5413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-381-0787
Provider Business Mailing Address Fax Number:
308-381-4632

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1811 W 2ND ST
Provider Second Line Business Practice Location Address:
SUITE 310
Provider Business Practice Location Address City Name:
GRAND ISLAND
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68803-5464
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-381-0787
Provider Business Practice Location Address Fax Number:
308-381-4632
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FLINT WIDDIFIELD
Authorized Official First Name:
LYNN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER SOLE THERAPIST
Authorized Official Telephone Number:
308-381-0787

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  1209 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10025443500 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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