1437455458 NPI number — WALNUT BOTTOM FAMILY PRACTICE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437455458 NPI number — WALNUT BOTTOM FAMILY PRACTICE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALNUT BOTTOM FAMILY PRACTICE, LLC
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:
1437455458
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
850 WALNUT BOTTOM RD
Provider Second Line Business Mailing Address:
SUITE 305
Provider Business Mailing Address City Name:
CARLISLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17013-3632
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-960-0052
Provider Business Mailing Address Fax Number:
717-960-0055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
850 WALNUT BOTTOM RD
Provider Second Line Business Practice Location Address:
SUITE 305
Provider Business Practice Location Address City Name:
CARLISLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17013-3632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-960-0052
Provider Business Practice Location Address Fax Number:
717-960-0055
Provider Enumeration Date:
02/09/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MYERS
Authorized Official First Name:
LISA
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
717-960-0052

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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