1174071310 NPI number — KIPER DEVELOPMENTAL THERAPY

Table of content: (NPI 1174071310)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174071310 NPI number — KIPER DEVELOPMENTAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIPER DEVELOPMENTAL THERAPY
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:
1174071310
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 WILDWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OWENSBORO
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42303-6147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-430-3122
Provider Business Mailing Address Fax Number:
270-640-0188

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 WILDWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OWENSBORO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42303-6147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-430-3122
Provider Business Practice Location Address Fax Number:
270-640-0188
Provider Enumeration Date:
09/16/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KIPER
Authorized Official First Name:
HOLLY
Authorized Official Middle Name:
MARX
Authorized Official Title or Position:
DEVELOPMENTAL INTERVENTIONIST
Authorized Official Telephone Number:
812-430-3122

Provider Taxonomy Codes

  • Taxonomy code: 252Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 252Y00000X , with the licence number: 201112352 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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