1427325265 NPI number — MISS THEADORA RUTH PETERSON LADC-1

Table of content: MISS THEADORA RUTH PETERSON LADC-1 (NPI 1427325265)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427325265 NPI number — MISS THEADORA RUTH PETERSON LADC-1

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
THEADORA
Provider Middle Name:
RUTH
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
LADC-1
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:
1427325265
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23 MEETING HOUSE HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST NEWBURY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01985-1509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-447-4043
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8 HARRIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWBURYPORT
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01950-2635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-447-4043
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/22/2011

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X , with the licence number: 22506 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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