1841430253 NPI number — TERRI L STEDDUM OD LLC

Table of content: (NPI 1841430253)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841430253 NPI number — TERRI L STEDDUM OD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TERRI L STEDDUM OD LLC
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:
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:
1841430253
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
412 EAGLERIDGE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUEBLO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81008-2100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-553-0917
Provider Business Mailing Address Fax Number:
719-553-0918

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8696 ECKBERG HTS
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLORADO SPRINGS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80924-8149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-299-5279
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/25/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
STEDDUM
Authorized Official First Name:
TERRI
Authorized Official Middle Name:
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
719-553-0917

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2700 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2700 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".