1720010382 NPI number — LINDA KAY FAIRCHILD OTR/L

Table of content: LINDA KAY FAIRCHILD OTR/L (NPI 1720010382)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720010382 NPI number — LINDA KAY FAIRCHILD OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAIRCHILD
Provider First Name:
LINDA
Provider Middle Name:
KAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
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:
1720010382
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1696 7TH STR. NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUFFALO
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-682-1223
Provider Business Mailing Address Fax Number:
763-682-1668

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1696 7TH ST NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUFFALO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55313-5050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-274-1070
Provider Business Practice Location Address Fax Number:
763-274-1071
Provider Enumeration Date:
07/06/2006

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: 225X00000X , with the licence number:  100400 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320900000X , with the licence number: 810345-1-WS , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 172360800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 218986-4-AFC . This is a "ADULT FOSTER CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 810345-1-WS . This is a "HOME AND COMMUNITY BASED" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".