1699045336 NPI number — DR. MACKENZIE JO STODOLA D.C.

Table of content: MICHELLE LEE YAGER PHARM D (NPI 1336709922)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699045336 NPI number — DR. MACKENZIE JO STODOLA D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STODOLA
Provider First Name:
MACKENZIE
Provider Middle Name:
JO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
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:
1699045336
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14020 HWY 13 S STE 650
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAVAGE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55378-7106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-447-8980
Provider Business Mailing Address Fax Number:
952-447-8941

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14020 HWY 13 S
Provider Second Line Business Practice Location Address:
650
Provider Business Practice Location Address City Name:
SAVAGE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55378-7100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-447-8980
Provider Business Practice Location Address Fax Number:
952-447-8941
Provider Enumeration Date:
01/11/2012

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: 111N00000X , with the licence number:  5590 , 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)