1689849556 NPI number — MS. BEVERLY ANTOINETTE LUCKETT-TORRENCE PTA

Table of content: MS. BEVERLY ANTOINETTE LUCKETT-TORRENCE PTA (NPI 1689849556)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689849556 NPI number — MS. BEVERLY ANTOINETTE LUCKETT-TORRENCE PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUCKETT-TORRENCE
Provider First Name:
BEVERLY
Provider Middle Name:
ANTOINETTE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PTA
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:
1689849556
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1300 S. GREEN BAY ROAD, SUITE #205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RACINE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-898-3930
Provider Business Mailing Address Fax Number:
262-898-3933

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
756 N 35TH ST STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-763-1237
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/23/2008

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: 225200000X , with the licence number:  976-019 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 976-019 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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