1104200179 NPI number — MR. PETER O'FALLON JR. ATC/LAT

Table of content: MR. PETER O'FALLON JR. ATC/LAT (NPI 1104200179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104200179 NPI number — MR. PETER O'FALLON JR. ATC/LAT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'FALLON
Provider First Name:
PETER
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
ATC/LAT
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:
1104200179
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
93 DUNE LAKES CIR
Provider Second Line Business Mailing Address:
B106
Provider Business Mailing Address City Name:
SANTA ROSA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32459-8393
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-952-7123
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4421 COMMONS DR E
Provider Second Line Business Practice Location Address:
SUITE-B 108
Provider Business Practice Location Address City Name:
DESTIN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32541-3484
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-460-2588
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/19/2015

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: 2255A2300X , with the licence number:  AL 4145 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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