1073819496 NPI number — TMRDLR LLC

Table of content: (NPI 1073819496)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073819496 NPI number — TMRDLR LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TMRDLR LLC
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:
6
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:
1073819496
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 424
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKAWVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62271-0424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-243-6228
Provider Business Mailing Address Fax Number:
618-243-5608

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
403 N HANOVER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKAWVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62271-1897
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-243-6228
Provider Business Practice Location Address Fax Number:
618-243-5608
Provider Enumeration Date:
02/02/2011

Additional Information

Authorized Official

Authorized Official Last Name:
RALLO
Authorized Official First Name:
DEANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
618-243-6228

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  054.017658 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1485374 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com