1326439605 NPI number — DR. ARIEL PETRACCA SELK L.AC., DACM

Table of content: DR. ARIEL PETRACCA SELK L.AC., DACM (NPI 1326439605)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326439605 NPI number — DR. ARIEL PETRACCA SELK L.AC., DACM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRACCA SELK
Provider First Name:
ARIEL
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
L.AC., DACM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PETRACCA
Provider Other First Name:
ARIEL
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
L.AC.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1326439605
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1608 WATERLOO AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH ST PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55075-1050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-321-5337
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14585 GRAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURNSVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55306-5719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-435-7349
Provider Business Practice Location Address Fax Number:
951-417-6159
Provider Enumeration Date:
02/09/2015

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: 171100000X , with the licence number:  1602 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com