1639131170 NPI number — AMY S. MANNING P.T.

Table of content: AMY S. MANNING P.T. (NPI 1639131170)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639131170 NPI number — AMY S. MANNING P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANNING
Provider First Name:
AMY
Provider Middle Name:
S.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FREDLUND
Provider Other First Name:
AMY
Provider Other Middle Name:
S.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
P.T.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639131170
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26 CONKEY AVE
Provider Second Line Business Mailing Address:
BOX 136
Provider Business Mailing Address City Name:
NORWICH
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13815-1756
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-895-4016
Provider Business Mailing Address Fax Number:
315-894-7326

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
33 CENTRAL PLZ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ILION
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13357-1701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-895-4016
Provider Business Practice Location Address Fax Number:
315-894-7326
Provider Enumeration Date:
04/03/2006

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 , with the licence number:  010764 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Q054D1 . This is a "EMPIRE BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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