1669742029 NPI number — WILDERNESS TRACE ANESTHESIA, PLLC

Table of content: (NPI 1669742029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669742029 NPI number — WILDERNESS TRACE ANESTHESIA, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILDERNESS TRACE ANESTHESIA, PLLC
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:
1669742029
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4860
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MURRELLS INLET
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29576-2698
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-651-2624
Provider Business Mailing Address Fax Number:
843-357-4940

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 S. 2ND ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40422-1804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-236-4008
Provider Business Practice Location Address Fax Number:
859-236-5025
Provider Enumeration Date:
01/03/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MITCHELL
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
843-651-2624

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  0805370 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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