1801295043 NPI number — SOUTHERN INDIANA MYOFASCIAL RELEASE, LLC

Table of content: (NPI 1801295043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801295043 NPI number — SOUTHERN INDIANA MYOFASCIAL RELEASE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN INDIANA MYOFASCIAL RELEASE, 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:
1801295043
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 NW 1ST ST STE D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAOLI
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47454-1369
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-788-1118
Provider Business Mailing Address Fax Number:
888-371-6163

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 NW 1ST ST STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAOLI
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47454-1369
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-788-1118
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/13/2014

Additional Information

Authorized Official

Authorized Official Last Name:
PARDY
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
812-788-1118

Provider Taxonomy Codes

  • Taxonomy code: 261QR0400X , with the licence number:  31005499A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com