1043342389 NPI number — LORETTA MAE SKELTON PLPC

Table of content: LORETTA MAE SKELTON PLPC (NPI 1043342389)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043342389 NPI number — LORETTA MAE SKELTON PLPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SKELTON
Provider First Name:
LORETTA
Provider Middle Name:
MAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PLPC
Provider Gender Code:
F

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:
1043342389
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:
PO BOX 612
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE OZARK
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65049-0612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-216-2216
Provider Business Mailing Address Fax Number:
573-348-9975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5740 HIGHWAY 54
Provider Second Line Business Practice Location Address:
LOWER LEVEL
Provider Business Practice Location Address City Name:
OSAGE BEACH
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65065-3086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-348-9979
Provider Business Practice Location Address Fax Number:
573-348-9975
Provider Enumeration Date:
03/12/2007

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: 101YP2500X , with the licence number:  2007002489 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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