1336235449 NPI number — THOMAS N LORENTZSEN & STANTON L ANDRIST PTR

Table of content: (NPI 1336235449)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336235449 NPI number — THOMAS N LORENTZSEN & STANTON L ANDRIST PTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THOMAS N LORENTZSEN & STANTON L ANDRIST PTR
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:
6
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:
1336235449
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 CENTER AVE
Provider Second Line Business Mailing Address:
SUITE 41
Provider Business Mailing Address City Name:
MOORHEAD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 CENTER AVE
Provider Second Line Business Practice Location Address:
SUITE 41
Provider Business Practice Location Address City Name:
MOORHEAD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-233-1624
Provider Business Practice Location Address Fax Number:
218-233-2058
Provider Enumeration Date:
10/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
IVERSON
Authorized Official First Name:
LYNN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CLAIMS SUPERVISOR
Authorized Official Telephone Number:
218-233-1624

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DG1558 . This is a "RR MEDICARE PIN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 281311400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 61093 . This is a "BCBS PIN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: DB3751 . This is a "RR MEDICARE PIN" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




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