1699968404 NPI number — HOMESTEAD PHYSICAL THERAPY PC

Table of content: (NPI 1699968404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699968404 NPI number — HOMESTEAD PHYSICAL THERAPY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOMESTEAD PHYSICAL THERAPY PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1699968404
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1146
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LARAMIE
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82073-1146
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-745-5434
Provider Business Mailing Address Fax Number:
307-745-5484

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1575 N 4TH ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
LARAMIE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82072-2091
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-745-5434
Provider Business Practice Location Address Fax Number:
307-745-5484
Provider Enumeration Date:
08/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HERKSTROETER
Authorized Official First Name:
LUANN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
307-745-5434

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DC9388 . This is a "MEDICARE RAILROAD CARRIER" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 01248/001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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