1578940409 NPI number — LARRY D ROTHENBERGER, INC

Table of content: (NPI 1578940409)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578940409 NPI number — LARRY D ROTHENBERGER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LARRY D ROTHENBERGER, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1578940409
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1253 S JACKSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRANKFORT
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46041-3312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-659-3351
Provider Business Mailing Address Fax Number:
765-659-9037

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1253 S JACKSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRANKFORT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46041-3312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-659-3351
Provider Business Practice Location Address Fax Number:
765-659-9037
Provider Enumeration Date:
04/29/2015

Additional Information

Authorized Official

Authorized Official Last Name:
RUTLEDGE
Authorized Official First Name:
VICKI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER/DENTAL HYGIENIST
Authorized Official Telephone Number:
765-659-3351

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  12007174A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100082810A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com