1518961242 NPI number — ROGER K BRANES PT

Table of content: ROGER K BRANES PT (NPI 1518961242)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518961242 NPI number — ROGER K BRANES PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRANES
Provider First Name:
ROGER
Provider Middle Name:
K
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:
1518961242
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 851
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CROIX FALLS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54024-0851
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-483-9221
Provider Business Mailing Address Fax Number:
715-483-1743

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 THOMPSON PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST CROIX FALLS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-483-9221
Provider Business Practice Location Address Fax Number:
715-483-1743
Provider Enumeration Date:
06/10/2005

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:  2172024 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 40110500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com