1952665416 NPI number — FUNCTIONAL ORAL MOTOR AND FEEDING CONCEPTS LLC

Table of content: (NPI 1952665416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952665416 NPI number — FUNCTIONAL ORAL MOTOR AND FEEDING CONCEPTS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FUNCTIONAL ORAL MOTOR AND FEEDING CONCEPTS 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:
1952665416
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6025 CONSTITUTION DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-438-3586
Provider Business Mailing Address Fax Number:
260-432-7046

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6205 CONSTITUTION DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46804-1517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-438-3586
Provider Business Practice Location Address Fax Number:
260-432-7046
Provider Enumeration Date:
06/29/2012

Additional Information

Authorized Official

Authorized Official Last Name:
GRIFFITH
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER/PROVIDER
Authorized Official Telephone Number:
260-438-3586

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200681320A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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