1871784330 NPI number — SALLY A TIMMONS LLC

Table of content: (NPI 1871784330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871784330 NPI number — SALLY A TIMMONS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SALLY A TIMMONS 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:
1871784330
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1805 SKYLINE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-404-6431
Provider Business Mailing Address Fax Number:
765-477-7843

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 SAGAMORE PARKWAY WEST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST LAFAYETTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-404-6431
Provider Business Practice Location Address Fax Number:
765-477-7843
Provider Enumeration Date:
08/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TIMMONS
Authorized Official First Name:
SALLY
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
REGISTERED AGENT
Authorized Official Telephone Number:
765-404-6431

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  34004910A , 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)

  • Identifier: 000000375779 . This is a "ANTHEM BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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