1013686120 NPI number — KARLA CECILIA CARRILLO LAZALDE

Table of content: KARLA CECILIA CARRILLO LAZALDE (NPI 1013686120)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013686120 NPI number — KARLA CECILIA CARRILLO LAZALDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARRILLO LAZALDE
Provider First Name:
KARLA
Provider Middle Name:
CECILIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CARRILLO LAZALDE
Provider Other First Name:
KC
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1013686120
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5831 N 23RD ST APT 108
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINCOLN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68521-1094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-627-6727
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1299 FARNAM ST STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68102-1857
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-235-1460
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/10/2021

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: 103K00000X , with the licence number:  RBT-21-179919 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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