1851532253 NPI number — MRS. LEAH MAE DEQUITADO BARREDO-RAGER P.T

Table of content: MRS. LEAH MAE DEQUITADO BARREDO-RAGER P.T (NPI 1851532253)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851532253 NPI number — MRS. LEAH MAE DEQUITADO BARREDO-RAGER P.T

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BARREDO-RAGER
Provider First Name:
LEAH MAE
Provider Middle Name:
DEQUITADO
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.T
Provider Gender Code:
F

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:
1851532253
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 TERRACE VIEW BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OREGON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61061-1044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-757-6514
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1234 S PARK BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREEPORT
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61032-4602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-616-5952
Provider Business Practice Location Address Fax Number:
815-616-5953
Provider Enumeration Date:
03/13/2009

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:  070016978 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 70016978 . This is a "PROFESSIONAL LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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