1427203827 NPI number — JUSTINE ANN BANTLE COTA

Table of content: JUSTINE ANN BANTLE COTA (NPI 1427203827)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427203827 NPI number — JUSTINE ANN BANTLE COTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BANTLE
Provider First Name:
JUSTINE
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
COTA
Provider Gender Code:
F

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:
1427203827
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
N2969 GREEN GABLE ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARINETTE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-735-8970
Provider Business Mailing Address Fax Number:
715-582-9115

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 WILLOW ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PESHTIGO
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-582-3962
Provider Business Practice Location Address Fax Number:
715-582-9115
Provider Enumeration Date:
11/26/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 224Z00000X , with the licence number:  1992-027 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 41073500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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