1811039043 NPI number — MRS. SUSAN ADELE DAVIS P.T.

Table of content: DR. RYAN SKALE D.D.S. (NPI 1194975797)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811039043 NPI number — MRS. SUSAN ADELE DAVIS P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
SUSAN
Provider Middle Name:
ADELE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1811039043
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:
296 EDGEWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUDSON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54016-7109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-381-6524
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1629 E DIVISION ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVER FALLS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54022-1571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-426-4537
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/13/2007

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: 225100000X , with the licence number:  6460-024 , 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: 36106000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com