1871036558 NPI number — AMANDA JEAN BARGENDER ATC, LAT, OTC

Table of content: AMANDA JEAN BARGENDER ATC, LAT, OTC (NPI 1871036558)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871036558 NPI number — AMANDA JEAN BARGENDER ATC, LAT, OTC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BARGENDER
Provider First Name:
AMANDA
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ATC, LAT, OTC
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:
1871036558
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1272 ARROWHEAD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARBOR VITAE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54568-9701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-370-6035
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1446 1ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODRUFF
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54568-9470
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-358-0610
Provider Business Practice Location Address Fax Number:
608-785-8674
Provider Enumeration Date:
11/29/2016

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: 2255A2300X , with the licence number:  2269-39 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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