1003388802 NPI number — FULLY ALIVE OCCUPATIONAL THERAPY

Table of content: (NPI 1003388802)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003388802 NPI number — FULLY ALIVE OCCUPATIONAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FULLY ALIVE OCCUPATIONAL THERAPY
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:
1003388802
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
404 W F ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH PLATTE
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
69101-5231
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-660-7867
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1002 E PHILIP AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH PLATTE
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
69101-6104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-532-4940
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/18/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MINCHOW
Authorized Official First Name:
MARCIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OCCUPATIONAL THERAPY
Authorized Official Telephone Number:
308-660-7867

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1629549860 . This is a "NPPES" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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