1316954985 NPI number — KARY J GILLENWATERS OTR/L

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316954985 NPI number — KARY J GILLENWATERS OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILLENWATERS
Provider First Name:
KARY
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REULE
Provider Other First Name:
KARY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LAC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1316954985
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15590 90TH ST NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OTSEGO
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55330-9452
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-755-4275
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15590 90TH ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OTSEGO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55330-9452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-755-4275
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  1458 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 018808 . This is a "BCBS OF ND PIN" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




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