1790874725 NPI number — VALARIE T EGGLESTON OTR

Table of content: VALARIE T EGGLESTON OTR (NPI 1790874725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790874725 NPI number — VALARIE T EGGLESTON OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EGGLESTON
Provider First Name:
VALARIE
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR
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:
1790874725
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1173 LIBERTY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREEN BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54304-3864
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-498-0061
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2900 CURRY LN
Provider Second Line Business Practice Location Address:
NEW CURATIVE REHABILITATION
Provider Business Practice Location Address City Name:
GREEN BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54311-5857
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-468-9129
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/11/2006

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: 225X00000X , with the licence number:  506-026 , 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: 40691500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".