1235174202 NPI number — CAROLYN GRACE PIERCE OTR/L

Table of content: CAROLYN GRACE PIERCE OTR/L (NPI 1235174202)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235174202 NPI number — CAROLYN GRACE PIERCE OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PIERCE
Provider First Name:
CAROLYN
Provider Middle Name:
GRACE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
Provider Gender Code:
F

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:
1235174202
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33656 S COTTON LAKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHERT
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56578-9688
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-846-2338
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
803 ROOSEVELT AVE
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
DETROIT LAKES
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56501-3744
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-844-5555
Provider Business Practice Location Address Fax Number:
218-844-6057
Provider Enumeration Date:
06/16/2006

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: 225X00000X , with the licence number:  102049 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2109395 . This is a "FIRST HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 64-04595 . This is a "MEDICA HEALTH INS." identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: P00086020 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 005J1PI . This is a "BLUECROSSBLUESHIELD-MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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