1932860632 NPI number — AMANDA REGESTER PEDIATRIC HEALTH SERVICES, LLC

Table of content: MYLES DEVIN RODGERS PT (NPI 1144888900)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932860632 NPI number — AMANDA REGESTER PEDIATRIC HEALTH SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMANDA REGESTER PEDIATRIC HEALTH SERVICES, 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:
1932860632
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1535 S ANDREW CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47401-7147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-450-8498
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
654 S WALKER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47403-2159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-369-4344
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/04/2022

Additional Information

Authorized Official

Authorized Official Last Name:
REGESTER
Authorized Official First Name:
AMANDA
Authorized Official Middle Name:
Authorized Official Title or Position:
SOLE-MEMBER
Authorized Official Telephone Number:
317-450-8498

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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