1689761116 NPI number — MR. RONALD DALE KNICKREHM PT

Table of content: MR. RONALD DALE KNICKREHM PT (NPI 1689761116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689761116 NPI number — MR. RONALD DALE KNICKREHM PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KNICKREHM
Provider First Name:
RONALD
Provider Middle Name:
DALE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

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:
1689761116
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1145 SWANSON DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA PORTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-324-4106
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2102 EAST EVANS AVENUE
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
VALPARAISO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46383-4096
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-476-0377
Provider Business Practice Location Address Fax Number:
219-476-0388
Provider Enumeration Date:
10/06/2006

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:  05001536A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000202146 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".




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