1205304763 NPI number — MR. EDWARD ALAN MATHIS LAC MA.

Table of content: MR. EDWARD ALAN MATHIS LAC MA. (NPI 1205304763)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205304763 NPI number — MR. EDWARD ALAN MATHIS LAC MA.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATHIS
Provider First Name:
EDWARD
Provider Middle Name:
ALAN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LAC MA.
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:
1205304763
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1220 GREELEY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALINA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67401-3330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-643-9778
Provider Business Mailing Address Fax Number:
785-819-3301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1220 GREELEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALINA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67401-3330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-643-9778
Provider Business Practice Location Address Fax Number:
785-819-3301
Provider Enumeration Date:
11/02/2018

Additional Information

Authorized Official

Authorized Official Last Name:
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Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  429 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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