1003278813 NPI number — BLAINE ANTHONY BIRTZER DAT, LAT, ATC

Table of content: BLAINE ANTHONY BIRTZER DAT, LAT, ATC (NPI 1003278813)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003278813 NPI number — BLAINE ANTHONY BIRTZER DAT, LAT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BIRTZER
Provider First Name:
BLAINE
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DAT, LAT, ATC
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:
1003278813
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1360 TERRACE DR APT 208
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55113-1774
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-214-3898
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1536 HEWITT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55104-1284
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-523-3094
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/22/2016

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: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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