1891917530 NPI number — MRS. SONDRA LOUISE HOLMES PT

Table of content: RICHARD T KLOOS (NPI 1275540031)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891917530 NPI number — MRS. SONDRA LOUISE HOLMES PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLMES
Provider First Name:
SONDRA
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1891917530
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
RR 4 BOX 4168
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18414-9741
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-222-4629
Provider Business Mailing Address Fax Number:
570-488-7154

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
476 BELMONT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAYMART
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18472-9304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-488-5100
Provider Business Practice Location Address Fax Number:
570-488-7154
Provider Enumeration Date:
05/03/2007

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:  PT005892-L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2299030 . This is a "AETNA" identifier , issued by the state of ( PW ) . This identifiers is of the category "OTHER".
  • Identifier: 808619 . This is a "FIRST PRIORITY HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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