1487895975 NPI number — DREW HITTENBERGER

Table of content: (NPI 1487895975)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487895975 NPI number — DREW HITTENBERGER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DREW HITTENBERGER
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:
HITTENBERGER ORTHOTICS AND PROSTHETICS, LLC
Provider Other Organization Name Type Code:
3
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:
1487895975
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 SONOMA AVE
Provider Second Line Business Mailing Address:
SUITE 320
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95405-4819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-765-1122
Provider Business Mailing Address Fax Number:
707-765-4571

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
181 LYNCH CREEK
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PETALUMA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94954
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-765-1122
Provider Business Practice Location Address Fax Number:
707-765-4571
Provider Enumeration Date:
03/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HITTENBERGER
Authorized Official First Name:
DREW
Authorized Official Middle Name:
ARNOLD
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
707-765-1122

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  CP 1093 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4129830001 . This is a "PTAN PETALUMA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 4129830006 . This is a "PTAN SANTA ROSA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 4129830007 . This is a "PTAN KENTFIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 4129830001 . This is a "MEDICARE SUPPLIER NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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