1053453266 NPI number — ANNE ELIZABETH BALLANTINE LAC

Table of content: ANNE ELIZABETH BALLANTINE LAC (NPI 1053453266)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053453266 NPI number — ANNE ELIZABETH BALLANTINE LAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALLANTINE
Provider First Name:
ANNE
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LAC
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:
1053453266
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 94
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RHINEBACK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12572
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-518-2059
Provider Business Mailing Address Fax Number:
845-876-5559

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6384 MILL STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RHINEBECK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-518-2059
Provider Business Practice Location Address Fax Number:
845-876-5559
Provider Enumeration Date:
02/13/2007

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: 171100000X , with the licence number:  000880 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 171100000X , with the licence number: AC5725 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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