1700076213 NPI number — BRYAN TREFFLEY BOURCIER DPT

Table of content: (NPI 1700034162)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700076213 NPI number — BRYAN TREFFLEY BOURCIER DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOURCIER
Provider First Name:
BRYAN
Provider Middle Name:
TREFFLEY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
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:
1700076213
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11130 PAKVIEW CIRCLE DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46845-1545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-266-7400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3946 ICE WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46805-1018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-266-4006
Provider Business Practice Location Address Fax Number:
260-266-4008
Provider Enumeration Date:
07/31/2007

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: 225100000X , with the licence number:  05009312A , 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)

  • Identifier: 156546 . This is a "GROUP MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200880200A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100257920 . This is a "GROUP MEDICAID" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com