1477911097 NPI number — CHENIN MARIE ROUDEBUSH PT, DPT

Table of content: CHENIN MARIE ROUDEBUSH PT, DPT (NPI 1477911097)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477911097 NPI number — CHENIN MARIE ROUDEBUSH PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROUDEBUSH
Provider First Name:
CHENIN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
YOUNG
Provider Other First Name:
CHENIN
Provider Other Middle Name:
MARIE
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:
1477911097
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18 MDG
Provider Second Line Business Mailing Address:
UNIT 5142
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AP
Provider Business Mailing Address Postal Code:
96368-5142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18 MDG
Provider Second Line Business Practice Location Address:
UNIT 5142
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AP
Provider Business Practice Location Address Postal Code:
96368-5142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
595-630-3532
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/10/2016

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: 225100000X , with the licence number:  1272137 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 303004 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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