1790866754 NPI number — THADDEUS DAVID LYNCH PT

Table of content: THADDEUS DAVID LYNCH PT (NPI 1790866754)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790866754 NPI number — THADDEUS DAVID LYNCH PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LYNCH
Provider First Name:
THADDEUS
Provider Middle Name:
DAVID
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

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:
1790866754
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
140 TIMBERLINE DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEEBE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-882-3359
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
710 MARION STREET
Provider Second Line Business Practice Location Address:
SUITE 102 BAPTIST HEALTH THERAPY CENTER
Provider Business Practice Location Address City Name:
SEARCY
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-268-2250
Provider Business Practice Location Address Fax Number:
501-268-2577
Provider Enumeration Date:
10/18/2006

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: 225100000X , with the licence number:  PT1935 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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