1508164039 NPI number — LYNAE MARIE HENINGER DPT, CSCS

Table of content: LYNAE MARIE HENINGER DPT, CSCS (NPI 1508164039)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508164039 NPI number — LYNAE MARIE HENINGER DPT, CSCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENINGER
Provider First Name:
LYNAE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT, CSCS
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:
1508164039
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3035 W MCMILLAN RD
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83646-6291
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-887-8684
Provider Business Mailing Address Fax Number:
208-887-9226

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3035 W MCMILLAN RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83646-6291
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-887-8684
Provider Business Practice Location Address Fax Number:
208-887-9226
Provider Enumeration Date:
03/08/2011

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:  1974 , 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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