1669774543 NPI number — KEITH WARREN WEIGOLD MS., CCC-SLP

Table of content: KEITH WARREN WEIGOLD MS., CCC-SLP (NPI 1669774543)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669774543 NPI number — KEITH WARREN WEIGOLD MS., CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEIGOLD
Provider First Name:
KEITH
Provider Middle Name:
WARREN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS., CCC-SLP
Provider Gender Code:
M

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:
1669774543
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
345 OASIS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BULLS GAP
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37711-2045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-438-8641
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 NETHERLAND LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37660-7245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-438-8641
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/24/2010

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: 235Z00000X , with the licence number:  13461 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: 4200 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1669774543 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".