1457740979 NPI number — MR. JEFFREY ALLEN CIESLAK LAT,AT,C, EMT

Table of content: MR. JEFFREY ALLEN CIESLAK LAT,AT,C, EMT (NPI 1457740979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457740979 NPI number — MR. JEFFREY ALLEN CIESLAK LAT,AT,C, EMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CIESLAK
Provider First Name:
JEFFREY
Provider Middle Name:
ALLEN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LAT,AT,C, EMT
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:
1457740979
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34565 MEADOW VIEW CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCONOMOWOC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53066-8778
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-853-1629
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 W RIVERWOODS PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-465-3000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/21/2015

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: 2255A2300X , with the licence number:  0000195-039 , 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)





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