1356434229 NPI number — LANCE E MALMSTROM DC, PA

Table of content: (NPI 1356434229)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356434229 NPI number — LANCE E MALMSTROM DC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LANCE E MALMSTROM DC, PA
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:
1356434229
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1520 SW TOPEKA AVE.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOPEKA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-235-1131
Provider Business Mailing Address Fax Number:
785-235-3771

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1520 SW TOPEKA AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOPEKA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-235-1131
Provider Business Practice Location Address Fax Number:
785-235-3771
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MALMSTROM
Authorized Official First Name:
LANCE
Authorized Official Middle Name:
ERIC
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
785-235-1131

Provider Taxonomy Codes

  • Taxonomy code: 111NX0800X , with the licence number:  01-03498 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 017503 . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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