1609926013 NPI number — CITY OF ELLENDALE

Table of content: (NPI 1609926013)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609926013 NPI number — CITY OF ELLENDALE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF ELLENDALE
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:
1609926013
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 267
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLENDALE
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58436-0267
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-349-3364
Provider Business Mailing Address Fax Number:
701-349-3333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 3RD AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELLENDALE
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-349-3364
Provider Business Practice Location Address Fax Number:
701-349-3333
Provider Enumeration Date:
01/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GULKE
Authorized Official First Name:
COREY
Authorized Official Middle Name:
ERWIN
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
701-349-3364

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  33 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2955-001 . This is a "BC-BS PROVIDER" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 590095437 . This is a "RAILROAD MEDICARE PROVIDE" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 52179 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9010790 . This is a "SD MEDICAID PROVIDER" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".




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