1073606679 NPI number — GARY LYNN CHILDERS DO

Table of content: GARY LYNN CHILDERS DO (NPI 1073606679)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073606679 NPI number — GARY LYNN CHILDERS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHILDERS
Provider First Name:
GARY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1073606679
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
353 FAIRMONT BLVD
Provider Second Line Business Mailing Address:
ATTEN MEDICAL STAFF SERVICES
Provider Business Mailing Address City Name:
RAPID CITY
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57701-6000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1420 N 10TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPEARFISH
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57783
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-642-8414
Provider Business Practice Location Address Fax Number:
605-642-8618
Provider Enumeration Date:
10/02/2006

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: 207R00000X , with the licence number:  4474 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com