1316135213 NPI number — MRS. CODI REBEKAH WARREN HEINZEROTH RD LD

Table of content: MRS. CODI REBEKAH WARREN HEINZEROTH RD LD (NPI 1316135213)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316135213 NPI number — MRS. CODI REBEKAH WARREN HEINZEROTH RD LD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WARREN HEINZEROTH
Provider First Name:
CODI
Provider Middle Name:
REBEKAH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD LD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HEINZEROTH
Provider Other First Name:
CODI
Provider Other Middle Name:
REBEKAH
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RD LD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1316135213
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9478 NE WOLF RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELGIN
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73538-2029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-492-6247
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4301 MOW WAY ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FT SILL
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73503-6300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-458-2500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/05/2007

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: 133V00000X , with the licence number:  1475 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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