1942593538 NPI number — WINGS OF HOPE COUNSELING SERVICES, PLLC

Table of content: BRYAN THOMAS IGLEHART JR. MD (NPI 1538253612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942593538 NPI number — WINGS OF HOPE COUNSELING SERVICES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WINGS OF HOPE COUNSELING SERVICES, PLLC
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:
1942593538
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 521
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANON CITY
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81215-0521
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-582-7839
Provider Business Mailing Address Fax Number:
877-582-7839

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1335 PHAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANON CITY
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81212-2334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-582-7839
Provider Business Practice Location Address Fax Number:
877-562-7839
Provider Enumeration Date:
05/16/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PEARSON
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
R
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
719-275-8714

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  4723 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X , with the licence number: 7038 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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