Provider Demographics
NPI:1285992909
Name:STUDENT
Entity type:Organization
Organization Name:STUDENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPY
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWARTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-891-7941
Mailing Address - Street 1:16554 N MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62675-6786
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16554 N MEADOW LN
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:IL
Practice Address - Zip Code:62675-6786
Practice Address - Country:US
Practice Address - Phone:217-891-7941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty