1104835768 NPI number — MRS. LEANN B YOUNG PAC

Table of content: MRS. LEANN B YOUNG PAC (NPI 1104835768)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104835768 NPI number — MRS. LEANN B YOUNG PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOUNG
Provider First Name:
LEANN
Provider Middle Name:
B
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PAC
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:
1104835768
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8600 N ROUTE 91
Provider Second Line Business Mailing Address:
SUITE 130
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-683-5059
Provider Business Mailing Address Fax Number:
309-683-5446

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8600 N ROUTE 91
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-683-5059
Provider Business Practice Location Address Fax Number:
309-683-5446
Provider Enumeration Date:
08/05/2006

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: 363AM0700X , with the licence number:  085001383 , 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: 920006568 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: P00608470 . This is a "RR MEDICARE GROUP MEMBER PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 434110 . This is a "MEDICARE GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CA4079 . This is a "RR MEDICARE GROUP PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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