1972589075 NPI number — TRISTAN ASSOCIATES

Table of content: MR. RODNEY KENT LEACH PT (NPI 1770972465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972589075 NPI number — TRISTAN ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRISTAN ASSOCIATES
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:
6
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:
1972589075
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4520 UNION DEPOSIT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARRISBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17111-2910
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-652-6105
Provider Business Mailing Address Fax Number:
717-652-2165

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28 SILVERMOON LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEWISBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17837-6354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-522-9300
Provider Business Practice Location Address Fax Number:
570-522-9304
Provider Enumeration Date:
12/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
DELOIA
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO TRISTAN ASSOCIATES
Authorized Official Telephone Number:
717-652-6105

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0671945 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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