1407420664 NPI number — FUNCTION FIRST SPINE AND SPORT, PLLC

Table of content: ASHANTI REGINA BOSTON LMHC, LPC, LCPC (NPI 1861023798)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407420664 NPI number — FUNCTION FIRST SPINE AND SPORT, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FUNCTION FIRST SPINE AND SPORT, PLLC
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:
1407420664
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1371 NELSON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT DODGE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50501-8534
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
525-570-7695
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
604 SUMNER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUMBOLDT
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50548-1761
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-570-7695
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/13/2021

Additional Information

Authorized Official

Authorized Official Last Name:
VANSICKLER
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
515-570-7695

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 111NS0005X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1235495615 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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