1013103373 NPI number — KIECA MD PLLC

Table of content: (NPI 1013103373)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013103373 NPI number — KIECA MD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIECA MD PLLC
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:
6
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:
1013103373
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 SE FRONTIER AVE
Provider Second Line Business Mailing Address:
SUITE A-1
Provider Business Mailing Address City Name:
CEDAREDGE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81413-4020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-856-3747
Provider Business Mailing Address Fax Number:
970-856-4814

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2050 SOUTH MAIN
Provider Second Line Business Practice Location Address:
UNIT B
Provider Business Practice Location Address City Name:
DELTA
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-874-4473
Provider Business Practice Location Address Fax Number:
970-874-8681
Provider Enumeration Date:
09/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CRAIG
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
KIECA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
970-856-3747

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  40224 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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