1992936025 NPI number — SUE L ROSCOE RD

Table of content: SUE L ROSCOE RD (NPI 1992936025)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992936025 NPI number — SUE L ROSCOE RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSCOE
Provider First Name:
SUE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OVERHOLT
Provider Other First Name:
SUE
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1992936025
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/06/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 608
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALMA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48801-0608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-466-3330
Provider Business Mailing Address Fax Number:
989-463-2540

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 E WARWICK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALMA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48801-1014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-466-3330
Provider Business Practice Location Address Fax Number:
989-463-2540
Provider Enumeration Date:
08/06/2009

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: 133VN1005X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 364144 . This is a "COMMISSION ON DIETETIC REGISTRATION" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".