1669771002 NPI number — MISS SHANNON KIM SWEENEY L.M.T

Table of content: MISS SHANNON KIM SWEENEY L.M.T (NPI 1669771002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669771002 NPI number — MISS SHANNON KIM SWEENEY L.M.T

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SWEENEY
Provider First Name:
SHANNON
Provider Middle Name:
KIM
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
L.M.T
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:
1669771002
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3380 MARIGOLD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRESCOTT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86305-3714
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-308-1053
Provider Business Mailing Address Fax Number:
928-778-5665

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3111 CLEARWATER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESCOTT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86305-7186
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-308-1053
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/24/2011

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: 225700000X , with the licence number:  MT-04194P , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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