1063542470 NPI number — KELLY L BOUNTING

Table of content: KELLY L BOUNTING (NPI 1063542470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063542470 NPI number — KELLY L BOUNTING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUNTING
Provider First Name:
KELLY
Provider Middle Name:
L
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:
MILLER
Provider Other First Name:
KELLY
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063542470
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19950 SOUTH PRAIRIE RD
Provider Second Line Business Mailing Address:
HENSCHELL CHIROPRACTIC
Provider Business Mailing Address City Name:
BONNEY LAKE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98391-7901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-862-1555
Provider Business Mailing Address Fax Number:
253-862-1557

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19950 SOUTH PRAIRIE RD
Provider Second Line Business Practice Location Address:
HENSCHELL CHIROPRACTIC
Provider Business Practice Location Address City Name:
BONNEY LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98391-7901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-862-1555
Provider Business Practice Location Address Fax Number:
253-862-1557
Provider Enumeration Date:
03/06/2007

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: 174400000X , with the licence number:  MA00012445 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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