1275643355 NPI number — BOST, INC.

Table of content: MRS. VICKI LEIGH KELLAM LICSW (NPI 1972686202)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275643355 NPI number — BOST, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOST, INC.
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:
6
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:
1275643355
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11495
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT SMITH
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72917-1495
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-478-5609
Provider Business Mailing Address Fax Number:
501-897-8339

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7701 S ZERO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT SMITH
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72903-6644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-784-1462
Provider Business Practice Location Address Fax Number:
479-784-1471
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STOUT
Authorized Official First Name:
FRANCIS
Authorized Official Middle Name:
LYNNE
Authorized Official Title or Position:
BILLING SUPERVISOR
Authorized Official Telephone Number:
479-478-5609

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X , with the licence number: 1275643355 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101Y00000X , with the licence number: A1204035 , 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: 109365213 . This is a "LONG TERM CARE MEDICAID" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 105894724 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 125833767 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 119694213 . This is a "LONG TERM CARE MEDICAID" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 133310782 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 149998775 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 177755526 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 109364213 . This is a "LONG TERM CARE MEDICAID" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 132538786 . This is a "STATE MEDICAID" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 178138724 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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