1124021084 NPI number — DOUGLAS E BALL OD PA

Table of content: (NPI 1124021084)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124021084 NPI number — DOUGLAS E BALL OD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOUGLAS E BALL OD PA
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:
SOUTHWIND EYECARE
Provider Other Organization Name Type Code:
3
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:
1124021084
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3120 N PLUM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUTCHINSON
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67502-2918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
620-662-2355
Provider Business Mailing Address Fax Number:
620-662-1102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3120 N PLUM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUTCHINSON
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67502-2918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-662-2355
Provider Business Practice Location Address Fax Number:
620-662-1102
Provider Enumeration Date:
05/24/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WHITTREDGE
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
LANE
Authorized Official Title or Position:
SECRETARY/TREASURER
Authorized Official Telephone Number:
620-662-2355

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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