1093730277 NPI number — DR. RICHARD KIPP ELLSWORTH D.O.

Table of content: SARA VACCARELLA PSYD (NPI 1245750652)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093730277 NPI number — DR. RICHARD KIPP ELLSWORTH D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLSWORTH
Provider First Name:
RICHARD
Provider Middle Name:
KIPP
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

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:
1093730277
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
460 GREENFIELD AVE
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
HANFORD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93230-3500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-584-0141
Provider Business Mailing Address Fax Number:
559-584-5711

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
460 GREENFIELD AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
HANFORD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93230-3500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-584-0141
Provider Business Practice Location Address Fax Number:
559-584-5711
Provider Enumeration Date:
07/12/2006

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: 204D00000X , with the licence number:  20A46140 , 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: 020A46140 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: A46140 . This is a "STATE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".