1316963036 NPI number — THERESA L KELSEY LPT

Table of content: THERESA L KELSEY LPT (NPI 1316963036)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316963036 NPI number — THERESA L KELSEY LPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELSEY
Provider First Name:
THERESA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1316963036
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1464 AMSTER GROVE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINCHESTER
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40391-8073
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
123 FRONTIER BLVD STE 106
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STANFORD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40484
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-257-0005
Provider Business Practice Location Address Fax Number:
606-262-4132
Provider Enumeration Date:
07/14/2006

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: 225100000X , with the licence number:  003869 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100508700 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com