1679857965 NPI number — MRS. RUTH A GODWIN WAGNER O.T.

Table of content: MRS. RUTH A GODWIN WAGNER O.T. (NPI 1679857965)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679857965 NPI number — MRS. RUTH A GODWIN WAGNER O.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GODWIN WAGNER
Provider First Name:
RUTH
Provider Middle Name:
A
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
O.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:
1679857965
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1776 POWDERLY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERLOO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13165-9415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-729-0779
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
212 E. DEZENG ST.
Provider Second Line Business Practice Location Address:
CLYDE ELEMENTARY SCHOOL
Provider Business Practice Location Address City Name:
CLYDE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-902-3100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/05/2011

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: 225X00000X , with the licence number:  005681-1 , 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)





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