1477664753 NPI number — MR. TIMOTHY LEE LEVENTRY LEVENTRY ORTL

Table of content: MR. TIMOTHY LEE LEVENTRY LEVENTRY ORTL (NPI 1477664753)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477664753 NPI number — MR. TIMOTHY LEE LEVENTRY LEVENTRY ORTL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEVENTRY
Provider First Name:
TIMOTHY
Provider Middle Name:
LEE LEVENTRY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
ORTL
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:
1477664753
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1397 EISENHOWER BLVD STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15904-3267
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-262-4236
Provider Business Mailing Address Fax Number:
814-262-4237

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1397 EISENHOWER BLVD
Provider Second Line Business Practice Location Address:
SUITE 304
Provider Business Practice Location Address City Name:
JOHNSTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15904-3262
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-262-4236
Provider Business Practice Location Address Fax Number:
814-262-4237
Provider Enumeration Date:
08/31/2006

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: 225X00000X , with the licence number:  0C006168L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1022150980001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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