1588669907 NPI number — BRADLEY DOUGLAS ORR PT, OCS

Table of content: BRADLEY DOUGLAS ORR PT, OCS (NPI 1588669907)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588669907 NPI number — BRADLEY DOUGLAS ORR PT, OCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ORR
Provider First Name:
BRADLEY
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, OCS
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:
1588669907
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1460
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ABERDEEN
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57402-1460
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-225-0430
Provider Business Mailing Address Fax Number:
605-225-0876

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 8TH AVE NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ABERDEEN
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57401-1865
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-225-0430
Provider Business Practice Location Address Fax Number:
605-225-0876
Provider Enumeration Date:
06/14/2005

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

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

  • Identifier: S831460 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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