1275743205 NPI number — DUNGARVIN INDIANA, LLC

Table of content: (NPI 1063489060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275743205 NPI number — DUNGARVIN INDIANA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DUNGARVIN INDIANA, LLC
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:
1275743205
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1444 NORTHLAND DR STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MENDOTA HEIGHTS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55120-1032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-699-0206
Provider Business Mailing Address Fax Number:
651-699-0799

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3575 MOREAU CT STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46628-4387
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-245-5400
Provider Business Practice Location Address Fax Number:
574-245-5440
Provider Enumeration Date:
05/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KRESS
Authorized Official First Name:
LORI
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
651-699-0206

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100239960 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100245120 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100245230 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100244770 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100244780 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100239800 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100244830 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100244950 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100230070 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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