1528064342 NPI number — DR. SARA JEAN CUPERUS D.C.

Table of content: DANIELLE WILLIAMS (NPI 1538965843)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528064342 NPI number — DR. SARA JEAN CUPERUS D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CUPERUS
Provider First Name:
SARA
Provider Middle Name:
JEAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KLEIN
Provider Other First Name:
SARA
Provider Other Middle Name:
JEAN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.C.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1528064342
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2380 TROOP DRIVE
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
SARTELL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56377-4637
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-255-0961
Provider Business Mailing Address Fax Number:
320-258-4001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2380 TROOP DRIVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
SARTELL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56377-4637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-255-0961
Provider Business Practice Location Address Fax Number:
320-258-4001
Provider Enumeration Date:
06/27/2005

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: 111NS0005X , with the licence number:  4331 , 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)

  • Identifier: 331J2CH . This is a "BCBS CLINIC PROVIDER #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: C03940 . This is a "MEDICARE CLINIC ID" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 332J9KL . This is a "BCBS INDIVIDUAL #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 350056798 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 777641100 . This is a "MN HEALTH CARE PROGRAMS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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