1134352289 NPI number — KELLVAN J CHENG, DPM, PA

Table of content: MR. KENDALL BRENNAN KNOBELOCH RN (NPI 1952831893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134352289 NPI number — KELLVAN J CHENG, DPM, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KELLVAN J CHENG, DPM, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ELITE FOOT & ANKLE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134352289
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4222 TRINITY MILLS ROAD
Provider Second Line Business Mailing Address:
112
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75287-7603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-710-1028
Provider Business Mailing Address Fax Number:
214-710-1029

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4222 TRINITY MILLS ROAD
Provider Second Line Business Practice Location Address:
112
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75287-7603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-710-1028
Provider Business Practice Location Address Fax Number:
214-710-1029
Provider Enumeration Date:
08/24/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CHENG
Authorized Official First Name:
KELLVAN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
FOOT & ANKLE SURGEON / PRESIDENT
Authorized Official Telephone Number:
214-710-1028

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  1763 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0042SV . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7127822 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".




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