1700074986 NPI number — LINDA S NEAL

Table of content: LINDA S NEAL (NPI 1700074986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700074986 NPI number — LINDA S NEAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NEAL
Provider First Name:
LINDA
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1700074986
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
285 N JANACEK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53045-6102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-641-9050
Provider Business Mailing Address Fax Number:
262-641-9126

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3535 30TH AVE
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
KENOSHA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53144-1632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-842-0500
Provider Business Practice Location Address Fax Number:
262-842-0502
Provider Enumeration Date:
10/12/2007

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: 101YA0400X , with the licence number:  11974-132 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 104100000X , with the licence number: 127436-121 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 39389800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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