1902171606 NPI number — JODI RANAE ROTHER HIS

Table of content: JODI RANAE ROTHER HIS (NPI 1902171606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902171606 NPI number — JODI RANAE ROTHER HIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROTHER
Provider First Name:
JODI
Provider Middle Name:
RANAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
HIS
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:
1902171606
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17316 KENYON AVE
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
LAKEVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55044-6909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-255-8579
Provider Business Mailing Address Fax Number:
952-255-8578

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17316 KENYON AVE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
LAKEVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55044-6909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-255-8579
Provider Business Practice Location Address Fax Number:
952-255-8578
Provider Enumeration Date:
03/13/2012

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: 174400000X , with the licence number:  2480 , 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)

  • Identifier: 2480 . This is a "MN DEPARTMENT OF HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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