1770822116 NPI number — HARUKA KELLEY

Table of content: HARUKA KELLEY (NPI 1770822116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770822116 NPI number — HARUKA KELLEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLEY
Provider First Name:
HARUKA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1770822116
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2350 W EL CAMINO REAL FL 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNTAIN VIEW
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94040-6203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-204-5600
Provider Business Mailing Address Fax Number:
510-506-7722

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 MILVIA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERKELEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-204-5600
Provider Business Practice Location Address Fax Number:
510-506-7722
Provider Enumeration Date:
02/05/2013

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: 363LP2300X , with the licence number:  95007416 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NP95007416 . This is a "STATE MEDICAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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