1437356904 NPI number — MR. DAVID KEITH NINER SLP

Table of content: MR. DAVID KEITH NINER SLP (NPI 1437356904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437356904 NPI number — MR. DAVID KEITH NINER SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NINER
Provider First Name:
DAVID
Provider Middle Name:
KEITH
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
SLP
Provider Gender Code:
M

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:
1437356904
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3414 COPPER HILL RUN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-459-0636
Provider Business Mailing Address Fax Number:
260-492-1674

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2827 NORTHGATE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46835-2903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-492-1400
Provider Business Practice Location Address Fax Number:
260-492-1674
Provider Enumeration Date:
06/28/2007

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: 235Z00000X , with the licence number:  22002728A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1555-656 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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