1740454065 NPI number — DR DAN KHAMPRASEUT

Table of content: (NPI 1740454065)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740454065 NPI number — DR DAN KHAMPRASEUT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR DAN KHAMPRASEUT
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:
ST CLAIR COUNTY CHIROPRACTIC & REHAB
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:
1740454065
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3620A N BELT W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLEVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62226-5947
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-233-3324
Provider Business Mailing Address Fax Number:
618-233-4758

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3620A N BELT W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLEVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62226-5947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-233-3324
Provider Business Practice Location Address Fax Number:
618-233-4758
Provider Enumeration Date:
04/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KHAMPRASEUT
Authorized Official First Name:
DAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
618-233-3324

Provider Taxonomy Codes

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

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

  • Identifier: 08009696 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8232072 . This is a "BCBS-IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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