1841316361 NPI number — MRS. TRACY CHAPIN VIRTA MA CCC A

Table of content: MRS. TRACY CHAPIN VIRTA MA CCC A (NPI 1841316361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841316361 NPI number — MRS. TRACY CHAPIN VIRTA MA CCC A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VIRTA
Provider First Name:
TRACY
Provider Middle Name:
CHAPIN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA CCC A
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VIRTA
Provider Other First Name:
TRACY
Provider Other Middle Name:
TICKNOR
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA CCC A
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1841316361
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
418 ISLAND VIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLAND
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49424-6098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-738-7412
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1445 SHELDON RD
Provider Second Line Business Practice Location Address:
HARBOR DUNES MEDICAL CENTER, SUITE 304
Provider Business Practice Location Address City Name:
GRAND HAVEN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49417-2480
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-935-6966
Provider Business Practice Location Address Fax Number:
616-935-6967
Provider Enumeration Date:
03/22/2007

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: 231H00000X , with the licence number:  1601000328 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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