1306912597 NPI number — AMY BOHL ATC

Table of content: AMY BOHL ATC (NPI 1306912597)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306912597 NPI number — AMY BOHL ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOHL
Provider First Name:
AMY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ATC
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:
1306912597
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:
791 OAK ST
Provider Second Line Business Mailing Address:
APT 8
Provider Business Mailing Address City Name:
PESHTIGO
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54157-1715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-582-0909
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3117 SHORE DR
Provider Second Line Business Practice Location Address:
SUITE 102-103
Provider Business Practice Location Address City Name:
MARINETTE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54143-4293
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-732-8200
Provider Business Practice Location Address Fax Number:
715-732-8205
Provider Enumeration Date:
11/28/2006

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:  451-039 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 451-039 . This is a "WISCONSIN LICENSE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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