1336331339 NPI number — TRI-MED HEALTH & WELLNESS CENTER, PC

Table of content: (NPI 1336331339)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336331339 NPI number — TRI-MED HEALTH & WELLNESS CENTER, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI-MED HEALTH & WELLNESS CENTER, PC
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:
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:
1336331339
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2709
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAVENPORT
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52809-2709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-823-5555
Provider Business Mailing Address Fax Number:
563-823-5556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4915 UTICA RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAVENPORT
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52807-3063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-823-5555
Provider Business Practice Location Address Fax Number:
563-823-5556
Provider Enumeration Date:
08/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MALLY
Authorized Official First Name:
MITCHELL
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
CLINIC DIRECTOR
Authorized Official Telephone Number:
563-823-5555

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: T01112 . This is a "UPIN" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 1192278 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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