1598346686 NPI number — SHEQUITTA WILKES MASSENBURG LRT, CTRS

Table of content: SHEQUITTA WILKES MASSENBURG LRT, CTRS (NPI 1598346686)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598346686 NPI number — SHEQUITTA WILKES MASSENBURG LRT, CTRS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MASSENBURG
Provider First Name:
SHEQUITTA
Provider Middle Name:
WILKES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LRT, CTRS
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:
1598346686
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3701 LOOP RD EAST
Provider Second Line Business Mailing Address:
REHAB MEDICINE-RECREATION THERAPY
Provider Business Mailing Address City Name:
TUSCALOSSA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-554-2000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3701 LOOP RD EAST
Provider Second Line Business Practice Location Address:
REHAB MEDICINE-RECREATION THERAPY
Provider Business Practice Location Address City Name:
TUSCALOSSA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-554-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/20/2021

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: 225800000X , with the licence number:  55100 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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