Basic Information
Provider Information | |||||||||
NPI: | 1093991093 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DONATELLE | ||||||||
FirstName: | JEFFREY | ||||||||
MiddleName: | ALAN | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 500 CROSS ST | ||||||||
Address2: |   | ||||||||
City: | BIG STONE CITY | ||||||||
State: | SD | ||||||||
PostalCode: | 572168237 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6055411140 | ||||||||
FaxNumber: | 6055410109 | ||||||||
Practice Location | |||||||||
Address1: | 15620 EDGEWOOD DR STE 240 | ||||||||
Address2: |   | ||||||||
City: | BAXTER | ||||||||
State: | MN | ||||||||
PostalCode: | 564016984 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2184547012 | ||||||||
FaxNumber: | 2184547015 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/21/2008 | ||||||||
LastUpdateDate: | 03/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 949-039 | WI | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 225100000X | 8517 | MN | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.