Basic Information
| Provider Information | |||||||||
| NPI: | 1235468729 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RESIDE | ||||||||
| FirstName: | TERRY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CST, SA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1604 VISA DR | ||||||||
| Address2: | |||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617612195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098464716 | ||||||||
| FaxNumber: | 3094541107 | ||||||||
| Practice Location | |||||||||
| Address1: | 1604 VISA DR | ||||||||
| Address2: | |||||||||
| City: | NORMAL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617612195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098464716 | ||||||||
| FaxNumber: | 3094541107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2009 | ||||||||
| LastUpdateDate: | 12/14/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | 238000219 | IL | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.