1487063772 NPI number — CHRISTINA VAN DER MEULEN L.AC.

Table of content: CHRISTINA VAN DER MEULEN L.AC. (NPI 1487063772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487063772 NPI number — CHRISTINA VAN DER MEULEN L.AC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN DER MEULEN
Provider First Name:
CHRISTINA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.AC.
Provider Gender Code:
F

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:
1487063772
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4588
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAILEY
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83333-4588
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-720-6513
Provider Business Mailing Address Fax Number:
208-788-2287

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
717 ELM ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLEVUE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-720-6513
Provider Business Practice Location Address Fax Number:
208-788-2287
Provider Enumeration Date:
08/12/2014

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: 171100000X , with the licence number:  ACU 140 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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