1609123462 NPI number — OUTSIDE THE LINES, 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 1609123462 NPI number — OUTSIDE THE LINES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OUTSIDE THE LINES, 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:
1609123462
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1772
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOVER
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03821-1772
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-286-6832
Provider Business Mailing Address Fax Number:
866-702-2502

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
DOVER
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03820-3882
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-286-6832
Provider Business Practice Location Address Fax Number:
866-702-2502
Provider Enumeration Date:
08/12/2012

Additional Information

Authorized Official

Authorized Official Last Name:
PRENDERGAST
Authorized Official First Name:
TAYLOR
Authorized Official Middle Name:
ELLEN
Authorized Official Title or Position:
PRINCIPAL PEDIATRIC OT
Authorized Official Telephone Number:
207-286-6832

Provider Taxonomy Codes

  • Taxonomy code: 225XP0200X , with the licence number:  2020 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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