1275158198 NPI number — JENNMIKE INC.

Table of content: (NPI 1275158198)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275158198 NPI number — JENNMIKE INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JENNMIKE INC.
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:
6
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:
1275158198
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1975 SAINT LUCIA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWBURGH
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47630-9668
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-246-9256
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 N GREEN RIVER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVANSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47715-2472
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-550-1444
Provider Business Practice Location Address Fax Number:
812-550-1441
Provider Enumeration Date:
06/16/2020

Additional Information

Authorized Official

Authorized Official Last Name:
CAGGIANO
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
SECRETARY/TREASURER
Authorized Official Telephone Number:
812-550-1444

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 69001599A . This is a "INDIANA PROFESSIONAL LICENSING AGENCY" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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