1003536871 NPI number — PIVOTAL HEALTH & WELLNESS INC

Table of content: (NPI 1003536871)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003536871 NPI number — PIVOTAL HEALTH & WELLNESS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PIVOTAL HEALTH & WELLNESS INC
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:
1003536871
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
314 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COURTLAND
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66939-3024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-955-0670
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
314 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COURTLAND
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66939-3024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-955-0670
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2022

Additional Information

Authorized Official

Authorized Official Last Name:
CARLSON
Authorized Official First Name:
ROBIN
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
785-955-0670

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: A-079-005 , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com