1851514442 NPI number — DR. STACY KOMMER LOTT DPT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851514442 NPI number — DR. STACY KOMMER LOTT DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOTT
Provider First Name:
STACY
Provider Middle Name:
KOMMER
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KOMMER
Provider Other First Name:
STACY
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1851514442
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3152 SEBE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUDSONVILLE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49426-7679
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:
3055 EAGLE PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-956-7900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/11/2007

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: 225100000X , with the licence number:  23166 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 5501013320 , 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)