1215089800 NPI number — BLAZING PRAIRIE STARS

Table of content: (NPI 1215089800)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215089800 NPI number — BLAZING PRAIRIE STARS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLAZING PRAIRIE STARS
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:
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:
1215089800
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:
47W635 BEITH ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAPLE PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60151-8802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-365-5550
Provider Business Mailing Address Fax Number:
630-365-9550

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
47W635 BEITH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAPLE PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60151-8802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-365-5550
Provider Business Practice Location Address Fax Number:
630-365-9550
Provider Enumeration Date:
01/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RAACK
Authorized Official First Name:
CATHERINE
Authorized Official Middle Name:
B
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
630-365-5550

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , 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: 04532110 . This is a "BLUE CROSS BLUE SHEILD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com