1538328109 NPI number — MRS. REGINA BRYANT MCKENZIE OTR

Table of content: MRS. REGINA BRYANT MCKENZIE OTR (NPI 1538328109)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538328109 NPI number — MRS. REGINA BRYANT MCKENZIE OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCKENZIE
Provider First Name:
REGINA
Provider Middle Name:
BRYANT
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRYANT
Provider Other First Name:
REGINA
Provider Other Middle Name:
KAY
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1538328109
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 EAGLE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DESOTO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75115-5472
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-230-1353
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 EAGLE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DESOTO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75115-5472
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-230-1353
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/08/2008

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: 225X00000X , with the licence number:  102442 , 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)





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