1639393275 NPI number — LORELEI LEIBLE NP

Table of content: LORELEI LEIBLE NP (NPI 1639393275)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639393275 NPI number — LORELEI LEIBLE NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEIBLE
Provider First Name:
LORELEI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

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:
1639393275
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 801143
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64180-1143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-331-5583
Provider Business Mailing Address Fax Number:
573-331-5079

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3250 GORDONVILLE RD
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
CAPE GIRARDEAU
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63703-5056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-334-9641
Provider Business Practice Location Address Fax Number:
573-331-4130
Provider Enumeration Date:
04/13/2007

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: 363LP0200X , with the licence number:  2002014828 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1639393275 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1639393275 . This is a "TRIWEST" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 926539 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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