1801955315 NPI number — DR. MYRA JEAN HECKENLAIBLE-GOTTO L.P.

Table of content: DR. MYRA JEAN HECKENLAIBLE-GOTTO L.P. (NPI 1801955315)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801955315 NPI number — DR. MYRA JEAN HECKENLAIBLE-GOTTO L.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HECKENLAIBLE-GOTTO
Provider First Name:
MYRA
Provider Middle Name:
JEAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
L.P.
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:
1801955315
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:
625 S MINNESOTA AVE
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57104-4871
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-334-7713
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1450 HIGHWAY 60 71 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINDOM
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56101-2025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-334-7713
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/08/2006

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: 103TC1900X , with the licence number:  LP4507 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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