1760712228 NPI number — MRS. SHANN LOURRAINE LEATHERMAN CMT, HHP

Table of content: MRS. SHANN LOURRAINE LEATHERMAN CMT, HHP (NPI 1760712228)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760712228 NPI number — MRS. SHANN LOURRAINE LEATHERMAN CMT, HHP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEATHERMAN
Provider First Name:
SHANN
Provider Middle Name:
LOURRAINE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CMT, HHP
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:
1760712228
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/06/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5159 E PARADISE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATTLE CREEK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49014-8333
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-209-6084
Provider Business Mailing Address Fax Number:
269-979-2026

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2510 SW CAPITAL AVE
Provider Second Line Business Practice Location Address:
SUITE104
Provider Business Practice Location Address City Name:
BATTLE CREEK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49015-4046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-209-6084
Provider Business Practice Location Address Fax Number:
269-979-2026
Provider Enumeration Date:
01/06/2010

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: 133N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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