1760613368 NPI number — GREGORY L. KANE OD PA

Table of content: (NPI 1760613368)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760613368 NPI number — GREGORY L. KANE OD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREGORY L. KANE OD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1760613368
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
514 S PALM AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALATKA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32177-4148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-328-8387
Provider Business Mailing Address Fax Number:
386-325-0644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
514 S PALM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALATKA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32177-4148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-328-8387
Provider Business Practice Location Address Fax Number:
386-325-0644
Provider Enumeration Date:
07/30/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BAGGETT
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
Authorized Official Title or Position:
OPTICIAN
Authorized Official Telephone Number:
386-328-8387

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OP-0001874 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 078282300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".