1144667197 NPI number — MR. SETH JEREMIAH REBEOR ATC

Table of content: MR. SETH JEREMIAH REBEOR ATC (NPI 1144667197)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144667197 NPI number — MR. SETH JEREMIAH REBEOR ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REBEOR
Provider First Name:
SETH
Provider Middle Name:
JEREMIAH
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
ATC
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:
1144667197
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
789 PINE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05401-4933
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-264-1052
Provider Business Mailing Address Fax Number:
802-264-1053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
414 ROUTE 7 S
Provider Second Line Business Practice Location Address:
UNIT 102
Provider Business Practice Location Address City Name:
MILTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05468-3807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-892-1413
Provider Business Practice Location Address Fax Number:
802-893-2253
Provider Enumeration Date:
05/31/2013

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:  0096034 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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