1578869806 NPI number — KERRY LE' CODY LMP

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 1578869806 NPI number — KERRY LE' CODY LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CODY
Provider First Name:
KERRY
Provider Middle Name:
LE'
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TATUM
Provider Other First Name:
KERRY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578869806
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8051
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YAKIMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98908-0051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-469-1903
Provider Business Mailing Address Fax Number:
509-469-1905

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3907 SUMMITVIEW AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YAKIMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98902-2716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-966-1640
Provider Business Practice Location Address Fax Number:
509-469-1905
Provider Enumeration Date:
02/03/2011

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: 225700000X , with the licence number:  MA60084213 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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