1760467823 NPI number — ACTRA REHABILITATION ASSOCIATES INC

Table of content: (NPI 1760467823)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760467823 NPI number — ACTRA REHABILITATION ASSOCIATES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACTRA REHABILITATION ASSOCIATES INC
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:
6
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:
1760467823
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4714 GETTYSBURG ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MECHANICSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10700 W BURLEIGH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53222-3310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-778-4500
Provider Business Practice Location Address Fax Number:
414-259-9465
Provider Enumeration Date:
12/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
TARVIN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
E
Authorized Official Title or Position:
VP & SECRETARY
Authorized Official Telephone Number:
717-972-1100

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 41790500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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