1285780478 NPI number — MRS. MARJORIE ANN SWANSON P.T.

Table of content: MRS. MARJORIE ANN SWANSON P.T. (NPI 1285780478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285780478 NPI number — MRS. MARJORIE ANN SWANSON P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SWANSON
Provider First Name:
MARJORIE
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1285780478
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:
2335 LAKE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VILLAGE OF LAKEWOOD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60014-5188
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-477-8593
Provider Business Mailing Address Fax Number:
815-477-0963

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2335 LAKE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VILLAGE OF LAKEWOOD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60014-5188
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-477-8593
Provider Business Practice Location Address Fax Number:
815-477-0963
Provider Enumeration Date:
01/28/2007

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: 2251P0200X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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