1245347459 NPI number — INNER DYNAMICS

Table of content: (NPI 1245347459)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245347459 NPI number — INNER DYNAMICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNER DYNAMICS
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:
1245347459
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8825 S. HOWELL AVE
Provider Second Line Business Mailing Address:
#305
Provider Business Mailing Address City Name:
OAK CREEK
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53154-3762
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-276-3856
Provider Business Mailing Address Fax Number:
414-235-9139

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8825 S. HOWELL AVE
Provider Second Line Business Practice Location Address:
#305
Provider Business Practice Location Address City Name:
OAK CREEK
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53154-3762
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-276-3856
Provider Business Practice Location Address Fax Number:
414-235-9139
Provider Enumeration Date:
08/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCHINGEN
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
LAU
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
414-276-3856

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 42110400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com