1770035982 NPI number — DYCORA TRANSITIONAL HEALTH - RIVERDALE, LLC

Table of content: PETER JOHN DEBUCK DMD (NPI 1013976232)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770035982 NPI number — DYCORA TRANSITIONAL HEALTH - RIVERDALE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DYCORA TRANSITIONAL HEALTH - RIVERDALE, LLC
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:
1770035982
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 N WISCONSIN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MUSCODA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53573-9115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-739-3186
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 N WISCONSIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MUSCODA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53573-9115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-739-3186
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/04/2016

Additional Information

Authorized Official

Authorized Official Last Name:
FOSTER
Authorized Official First Name:
SEAN
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
317-786-3230

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  3188 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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