1104576479 NPI number — KAYLA EDSON, PLLC

Table of content: (NPI 1104576479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104576479 NPI number — KAYLA EDSON, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KAYLA EDSON, 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:
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:
1104576479
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4689 W 20TH STREET
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
GREELEY
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-834-3657
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4689 W 20TH STREET
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
GREELEY
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-834-3657
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/28/2022

Additional Information

Authorized Official

Authorized Official Last Name:
EDSON
Authorized Official First Name:
KAYLA
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
970-834-3657

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 62308 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 60054 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: RMHMO , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: COACC , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 87726 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00813 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9000177607 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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