1609147461 NPI number — LEONARD TRENT WONNENBERG PAC

Table of content: LEONARD TRENT WONNENBERG PAC (NPI 1609147461)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609147461 NPI number — LEONARD TRENT WONNENBERG PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WONNENBERG
Provider First Name:
LEONARD
Provider Middle Name:
TRENT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
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:
1609147461
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
602 1ST ST NE STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESSINGTON SPRINGS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57382-2163
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-539-9836
Provider Business Mailing Address Fax Number:
605-539-9546

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 18TH ST SW
Provider Second Line Business Practice Location Address:
STE 27
Provider Business Practice Location Address City Name:
HURON
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57350-3486
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-554-1015
Provider Business Practice Location Address Fax Number:
605-554-1016
Provider Enumeration Date:
01/25/2012

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: 363A00000X , with the licence number:  0803 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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