1114901451 NPI number — KENNY A DE LUCA P.T.

Table of content: KENNY A DE LUCA P.T. (NPI 1114901451)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114901451 NPI number — KENNY A DE LUCA P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE LUCA
Provider First Name:
KENNY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1114901451
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 13567
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAUMELLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72113-0567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-753-2201
Provider Business Mailing Address Fax Number:
501-753-2207

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9843 MAUMELLE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72113-7027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-753-2201
Provider Business Practice Location Address Fax Number:
501-753-2207
Provider Enumeration Date:
11/30/2005

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: 225100000X , with the licence number:  PT2475 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5F332 . This is a "AR BCBS GROUP" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 5W795 . This is a "AR BCBS INDIVIDUAL" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com