1033940069 NPI number — ROSSENERY CACERES PT, DPT, AIB-VRC

Table of content: ROSSENERY CACERES PT, DPT, AIB-VRC (NPI 1033940069)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033940069 NPI number — ROSSENERY CACERES PT, DPT, AIB-VRC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CACERES
Provider First Name:
ROSSENERY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, AIB-VRC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CACERES
Provider Other First Name:
ROSE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1033940069
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8682 N RIDGE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERRIEN SPRINGS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49103-1457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-697-3724
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3630 TENNIS CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT JOSEPH
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49085-9502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-210-5534
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/12/2024

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: 225100000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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