1720318645 NPI number — JLAAT

Table of content: (NPI 1720318645)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720318645 NPI number — JLAAT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JLAAT
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:
6
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:
1720318645
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4114 BROOKSTON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45502-8622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-233-4055
Provider Business Mailing Address Fax Number:
937-233-4077

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8501 OLD TROY PIKE
Provider Second Line Business Practice Location Address:
SUITE 190
Provider Business Practice Location Address City Name:
HUBER HEIGHTS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45424-1054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-233-4055
Provider Business Practice Location Address Fax Number:
937-233-4077
Provider Enumeration Date:
12/29/2009

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
LEIGH
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
937-233-4055

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3455 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: JT9386591 . This is a "MEDICARE PTAN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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