1568837490 NPI number — STACIE OPAHLE

Table of content: STACIE OPAHLE (NPI 1568837490)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568837490 NPI number — STACIE OPAHLE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OPAHLE
Provider First Name:
STACIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1568837490
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
625 RIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLGATE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53017-9527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-213-8997
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
W156N8327 PILGRIM RD
Provider Second Line Business Practice Location Address:
STE 408
Provider Business Practice Location Address City Name:
MENOMONEE FALLS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53051-3776
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-395-8106
Provider Business Practice Location Address Fax Number:
414-386-0406
Provider Enumeration Date:
12/03/2015

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: 374U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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