1578937686 NPI number — TIMOTHY LUKE FENDER ATC

Table of content: TIMOTHY LUKE FENDER ATC (NPI 1578937686)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578937686 NPI number — TIMOTHY LUKE FENDER ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FENDER
Provider First Name:
TIMOTHY
Provider Middle Name:
LUKE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ATC
Provider Gender Code:
M

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:
1578937686
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PSC 76 BOX 2921
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AP
Provider Business Mailing Address Postal Code:
96319-0030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-980-4005
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HIRAHATA 64 MISAWA-KICHI
Provider Second Line Business Practice Location Address:
BUILDING #656
Provider Business Practice Location Address City Name:
MISAWA-SHI
Provider Business Practice Location Address State Name:
AOMORI-KEN
Provider Business Practice Location Address Postal Code:
0330012
Provider Business Practice Location Address Country Code:
JP
Provider Business Practice Location Address Telephone Number:
315-226-1051
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/01/2015

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: 2255A2300X , with the licence number:  2864 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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