Basic Information
Provider Information | |||||||||
NPI: | 1336256908 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DEBOER | ||||||||
FirstName: | ARLIN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 34 | ||||||||
Address2: |   | ||||||||
City: | KENT | ||||||||
State: | CT | ||||||||
PostalCode: | 067570034 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8609274559 | ||||||||
FaxNumber: | 8609273352 | ||||||||
Practice Location | |||||||||
Address1: | 64 MAPLE ST. | ||||||||
Address2: |   | ||||||||
City: | KENT | ||||||||
State: | CT | ||||||||
PostalCode: | 067570034 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8609274559 | ||||||||
FaxNumber: | 8609273352 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/23/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 004702 | CT | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 575838 | 01 | CT | CONNECTICARE PROVIDER | OTHER | 15901 | 01 | CT | CIGNA ORTHONET PROVIDER | OTHER | P2057224 | 01 | NY | OXFORD OUT OF NETWORK PRO | OTHER | 2288136 | 01 | CT | AETNA PROVIDER | OTHER | 64-04275 | 01 | CT | UNITED HEALTH CARE PROVID | OTHER | OV6316 | 01 | CT | HEALTH NET PROVIDER | OTHER | QA6291 | 01 | NY | EMPIRE | OTHER | 437034 | 01 | NY | MVP PROVIDER | OTHER | 0800004702CT01 | 01 | CT | ANTHEM BC/BS PROVIDER | OTHER |