1770539827 NPI number — THEODORE E MOLLERUD

Table of content: THEODORE E MOLLERUD (NPI 1770539827)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770539827 NPI number — THEODORE E MOLLERUD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOLLERUD
Provider First Name:
THEODORE
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1770539827
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2215 E CLAIREMONT AVE
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
EAU CLAIRE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54701-4772
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-831-0289
Provider Business Mailing Address Fax Number:
715-831-4722

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2215 E CLAIREMONT AVE
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
EAU CLAIRE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54701-4772
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-831-0289
Provider Business Practice Location Address Fax Number:
715-831-4722
Provider Enumeration Date:
05/26/2006

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: 231H00000X , with the licence number:  30-156 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 42813100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com