1477174381 NPI number — SARAH ROSS SAC-IT

Table of content: SARAH ROSS SAC-IT (NPI 1477174381)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477174381 NPI number — SARAH ROSS SAC-IT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSS
Provider First Name:
SARAH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SAC-IT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NANCE
Provider Other First Name:
SARAH
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477174381
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
LA CLINICA DE LOS CAMPESINOS, INC.
Provider Second Line Business Mailing Address:
PO BOX 1440
Provider Business Mailing Address City Name:
WAUTOMA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54982-6922
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-787-5514
Provider Business Mailing Address Fax Number:
920-787-4737

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
302 WEST LAKE ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRIENDSHIP
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
55934
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-787-5514
Provider Business Practice Location Address Fax Number:
920-787-4737
Provider Enumeration Date:
05/01/2020

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: 101YA0400X , with the licence number:  18665-130 , 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)





Copyright © 2007-2025 www.npivalidator.com