1710425210 NPI number — MR. TANNER RAY TIMMERMAN PT, DPT

Table of content: MR. TANNER RAY TIMMERMAN PT, DPT (NPI 1710425210)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710425210 NPI number — MR. TANNER RAY TIMMERMAN PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TIMMERMAN
Provider First Name:
TANNER
Provider Middle Name:
RAY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
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:
1710425210
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
625 ENTERPRISE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK BROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60523-8813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-575-1980
Provider Business Mailing Address Fax Number:
630-928-5080

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 W BROADWAY STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COUNCIL BLUFFS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51503-9071
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-322-9688
Provider Business Practice Location Address Fax Number:
712-322-1299
Provider Enumeration Date:
02/03/2017

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:  3673 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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