Basic Information
| Provider Information | |||||||||
| NPI: | 1851996763 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POPOVICH | ||||||||
| FirstName: | SETH | ||||||||
| MiddleName: | TYLER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1713 SANDRA ST | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618211408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173904706 | ||||||||
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| Practice Location | |||||||||
| Address1: | 404 BROOKVIEW DR, FARMER CITY | ||||||||
| Address2: | |||||||||
| City: | FRAMER CITY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3099282118 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2020 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.