1164475612 NPI number — ADDISON WELLNESS INC

Table of content: (NPI 1164475612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164475612 NPI number — ADDISON WELLNESS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADDISON WELLNESS INC
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:
1164475612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 764
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLEBURY
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05753
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-388-3533
Provider Business Mailing Address Fax Number:
802-388-2334

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
175 WILSON RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
MIDDLEBURY
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-388-3533
Provider Business Practice Location Address Fax Number:
802-388-2334
Provider Enumeration Date:
05/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HORNE
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
WOEHLKE
Authorized Official Title or Position:
PRESIDENT PHYSICAL THERAPIST
Authorized Official Telephone Number:
802-388-3533

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 69230 . This is a "BCBS" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com