1730611138 NPI number — WAYNE SPORT AND SPINE CENTER, LLC

Table of content: (NPI 1730611138)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730611138 NPI number — WAYNE SPORT AND SPINE CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAYNE SPORT AND SPINE CENTER, LLC
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:
WAYNE SPORT & SPINE
Provider Other Organization Name Type Code:
3
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:
1730611138
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/14/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
214 N PEARL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAYNE
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68787-1902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-375-3000
Provider Business Mailing Address Fax Number:
402-375-1866

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
214 N PEARL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAYNE
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68787-1902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-375-3000
Provider Business Practice Location Address Fax Number:
402-375-1866
Provider Enumeration Date:
04/03/2017

Additional Information

Authorized Official

Authorized Official Last Name:
KENNY
Authorized Official First Name:
LEVI
Authorized Official Middle Name:
ERVIN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
402-369-2017

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1935 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com