1760540926 NPI number — MATCH PLAY TENNIS CENTERS, INC.

Table of content: TODD RICHARD GUSTAFSON CRNA (NPI 1770560021)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760540926 NPI number — MATCH PLAY TENNIS CENTERS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MATCH PLAY TENNIS CENTERS, 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:
1760540926
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 COLLINS RD NE
Provider Second Line Business Mailing Address:
BLDG 154-100
Provider Business Mailing Address City Name:
CEDAR RAPIDS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52498-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-295-8899
Provider Business Mailing Address Fax Number:
319-295-8833

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 COLLINS RD NE
Provider Second Line Business Practice Location Address:
BLDG 154-100
Provider Business Practice Location Address City Name:
CEDAR RAPIDS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52498-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-295-8899
Provider Business Practice Location Address Fax Number:
319-295-8833
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FOX
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
W
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
319-295-8899

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  NA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1066154 . This is a "USAMCO GROUP NUMBER" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 37850 . This is a "WELLMARK GROUP NUMBER" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: F245873 . This is a "MIDLANDS CHOICE ID NUMBER" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 5747352 . This is a "FIRST HEALTH GROUP NUMBER" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com