1609132240 NPI number — MISS BRITTANY ANN KOMASINSKI DT

Table of content: MISS BRITTANY ANN KOMASINSKI DT (NPI 1609132240)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609132240 NPI number — MISS BRITTANY ANN KOMASINSKI DT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOMASINSKI
Provider First Name:
BRITTANY
Provider Middle Name:
ANN
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
DT
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:
1609132240
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11075 OREGON LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CROWN POINT
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46307-5282
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-730-2961
Provider Business Mailing Address Fax Number:
866-463-2060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5201 FOUNTAIN DR
Provider Second Line Business Practice Location Address:
STE D
Provider Business Practice Location Address City Name:
CROWN POINT
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46307-5324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-796-9335
Provider Business Practice Location Address Fax Number:
866-463-2060
Provider Enumeration Date:
04/09/2012

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: 222Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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