1245421387 NPI number — DAVID TERRY LETOURNEAU LATC

Table of content: DAVID TERRY LETOURNEAU LATC (NPI 1245421387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245421387 NPI number — DAVID TERRY LETOURNEAU LATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LETOURNEAU
Provider First Name:
DAVID
Provider Middle Name:
TERRY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LATC
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:
1245421387
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7 RUSS STREET
Provider Second Line Business Mailing Address:
CENTER FOR INTEGRATED NEURO-REHAB
Provider Business Mailing Address City Name:
CARIBOU
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-498-3820
Provider Business Mailing Address Fax Number:
207-498-3591

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7 RUSS STREET
Provider Second Line Business Practice Location Address:
CENTER FOR INTEGRATED NEURO-REHAB
Provider Business Practice Location Address City Name:
CARIBOU
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-498-3820
Provider Business Practice Location Address Fax Number:
207-498-3591
Provider Enumeration Date:
08/05/2007

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: 2255A2300X , with the licence number:  AT153 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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