1982787404 NPI number — ROBERT M VAN WINKLE CCDC3

Table of content: ROBERT M VAN WINKLE CCDC3 (NPI 1982787404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982787404 NPI number — ROBERT M VAN WINKLE CCDC3

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN WINKLE
Provider First Name:
ROBERT
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CCDC3
Provider Gender Code:
M

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:
1982787404
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:
202 S MAIN STREET
Provider Second Line Business Mailing Address:
SUITE 228
Provider Business Mailing Address City Name:
ABERDEEN
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57401-4114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-229-1500
Provider Business Mailing Address Fax Number:
605-229-4357

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 S MAIN STREET
Provider Second Line Business Practice Location Address:
SUITE 228
Provider Business Practice Location Address City Name:
ABERDEEN
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57401-4114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-229-1500
Provider Business Practice Location Address Fax Number:
605-229-4357
Provider Enumeration Date:
10/21/2006

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: 101Y00000X , with the licence number:  CCDC3 9607910 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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