1902519416 NPI number — FUNCTIONAL PILATES LLC

Table of content: KAREN LEE DUMARS MD (NPI 1417059346)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902519416 NPI number — FUNCTIONAL PILATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FUNCTIONAL PILATES 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:
1902519416
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1725 S CALIFORNIA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALATINE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60067-7527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-612-0530
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1725 S CALIFORNIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALATINE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60067-7527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-612-0530
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/29/2022

Additional Information

Authorized Official

Authorized Official Last Name:
SHEADE
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
847-612-0530

Provider Taxonomy Codes

  • Taxonomy code: 225XP0019X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 056009012 . This is a "APPLYING TO BCBS NETWORK" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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