1619161577 NPI number — MR. DAN PATRICK DUNLEAVY JR. LAT, ATC

Table of content: MR. DAN PATRICK DUNLEAVY JR. LAT, ATC (NPI 1619161577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619161577 NPI number — MR. DAN PATRICK DUNLEAVY JR. LAT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DUNLEAVY
Provider First Name:
DAN
Provider Middle Name:
PATRICK
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
LAT, ATC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DUNLEAVY
Provider Other First Name:
DANIEL
Provider Other Middle Name:
PATRICK
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
JR.
Provider Other Credential Text:
LAT, ATC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1619161577
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/04/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1437 TIPPECANOE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TERRE HAUTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47807-2246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
267-577-1086
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 N 7TH ST
Provider Second Line Business Practice Location Address:
ATHLETIC TRAINING DEPARTMENT C-06 INDIANA STATE UNIV
Provider Business Practice Location Address City Name:
TERRE HAUTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47809-1902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-237-8232
Provider Business Practice Location Address Fax Number:
812-237-4368
Provider Enumeration Date:
09/04/2007

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:  36001426A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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