1881295590 NPI number — FUNCTIONAL KIDS, PLLC

Table of content: (NPI 1881295590)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881295590 NPI number — FUNCTIONAL KIDS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FUNCTIONAL KIDS, PLLC
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:
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Provider Other Name Prefix Text:
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NPI Number Information

NPI Number:
1881295590
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5108 E VILLA RIDGE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57110-8542
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-359-3827
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5108 E VILLA RIDGE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57110-8542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-359-3827
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/09/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FLUTH
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
Authorized Official Title or Position:
OCCUPATIONAL THERAPIST
Authorized Official Telephone Number:
605-359-3827

Provider Taxonomy Codes

  • Taxonomy code: 225XP0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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