1497061782 NPI number — BRET MAIERS PT

Table of content: BRET MAIERS PT (NPI 1497061782)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497061782 NPI number — BRET MAIERS PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAIERS
Provider First Name:
BRET
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1497061782
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 FLANDRO DR 190
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83202-1975
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-233-2248
Provider Business Mailing Address Fax Number:
208-233-0219

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
220 MILLPOND
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
STANSBURY PARK
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84074-9745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-882-4144
Provider Business Practice Location Address Fax Number:
435-882-4151
Provider Enumeration Date:
08/24/2010

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:  PT60168625 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 8715597-2401 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1497061782 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1497061782 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00877701 . This is a "RR MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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