1669765566 NPI number — MRS. STEPHANIE STARCK SKEBA RD, LD, CPT

Table of content: MRS. STEPHANIE STARCK SKEBA RD, LD, CPT (NPI 1669765566)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669765566 NPI number — MRS. STEPHANIE STARCK SKEBA RD, LD, CPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SKEBA
Provider First Name:
STEPHANIE
Provider Middle Name:
STARCK
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD, LD, CPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STARCK
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1669765566
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 FORD ROAD
Provider Second Line Business Mailing Address:
UNIT 5
Provider Business Mailing Address City Name:
ST LOUIS PARK
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-670-7116
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1825 WOODWINDS DR
Provider Second Line Business Practice Location Address:
WAYS TO WELLNESS
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55125-2202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-232-1926
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/25/2011

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: 133V00000X , with the licence number:  2946 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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