1629196340 NPI number — THE RESIDENTIAL DEVELOPERS, INC.

Table of content: KAREN COURTNEY SHELLENBARGER NP (NPI 1053568048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629196340 NPI number — THE RESIDENTIAL DEVELOPERS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE RESIDENTIAL DEVELOPERS, INC.
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:
1629196340
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6525
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAMPAIGN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61826-6525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-398-0754
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 W ENZ AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CISSNA PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60924-9795
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-547-2214
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NEWTON
Authorized Official First Name:
SHERRY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
217-398-0754

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X , with the licence number:  0035279 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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