1952611873 NPI number — ALPINE SUPPLY, LLC

Table of content: MS. LAURA ANN BOUZAN MASTER OF SOCIAL WOR (NPI 1366597452)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952611873 NPI number — ALPINE SUPPLY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALPINE SUPPLY, LLC
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:
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:
1952611873
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7451 WILES RD STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORAL SPRINGS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33067-2040
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:
2536 PLOVER ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLOVER
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54467-3926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-345-1771
Provider Business Practice Location Address Fax Number:
715-345-0359
Provider Enumeration Date:
10/13/2010

Additional Information

Authorized Official

Authorized Official Last Name:
VASTA
Authorized Official First Name:
PHILIP
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
561-289-9988

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6544280001 . This is a "PTAN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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