=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124612734
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDWEST RNFA PROVIDERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2021
-----------------------------------------------------
Last Update Date | 02/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12140 N RIVER RD
-----------------------------------------------------
City | MEQUON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53092-2218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-227-2457
-----------------------------------------------------
Fax | 214-764-0880
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2550
-----------------------------------------------------
City | ROWLETT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75030-2550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-227-2457
-----------------------------------------------------
Fax | 214-764-0880
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ERIKA LIVINGSTON
-----------------------------------------------------
Credential | RNFA SAC
-----------------------------------------------------
Telephone | 414-943-6128
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------