1760902795 NPI number — RICHARD JOHN O'DONNELL III OTR/L

Table of content: RICHARD JOHN O'DONNELL III OTR/L (NPI 1760902795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760902795 NPI number — RICHARD JOHN O'DONNELL III OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'DONNELL
Provider First Name:
RICHARD
Provider Middle Name:
JOHN
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
OTR/L
Provider Gender Code:
M

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:
1760902795
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2616 ALHAMBRA CT # A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63118-1116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 S BELT W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLEVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62220-2503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-277-7700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/21/2017

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: 225X00000X , with the licence number:  056011293 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com