1336689322 NPI number — ST. JOHN'S LUTHERAN CHURCH, INC.

Table of content: NGOZI ANDRADE MESSAM RN (NPI 1356838254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336689322 NPI number — ST. JOHN'S LUTHERAN CHURCH, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. JOHN'S LUTHERAN CHURCH, INC.
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:
1336689322
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
311 N. LAKE R. P. O BOX 172
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LENA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61048-8712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-369-2690
Provider Business Mailing Address Fax Number:
815-369-2535

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
311 N. LAKE RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LENA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61048-8712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-369-2690
Provider Business Practice Location Address Fax Number:
815-369-2535
Provider Enumeration Date:
02/24/2017

Additional Information

Authorized Official

Authorized Official Last Name:
NOLAN
Authorized Official First Name:
FAWN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHAIRMAN OF THE BOARD
Authorized Official Telephone Number:
815-369-4035

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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