1316935687 NPI number — KELLI ANN COLEMAN OTRL CHT

Table of content: KELLI ANN COLEMAN OTRL CHT (NPI 1316935687)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316935687 NPI number — KELLI ANN COLEMAN OTRL CHT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLEMAN
Provider First Name:
KELLI
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTRL CHT
Provider Gender Code:
F

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:
1316935687
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
690 N COFCO CENTER CT
Provider Second Line Business Mailing Address:
SUITE 260
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85008-6462
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-279-6905
Provider Business Mailing Address Fax Number:
888-445-4263

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
690 N COFCO CENTER CT
Provider Second Line Business Practice Location Address:
SUITE 260
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85008-6462
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-279-6905
Provider Business Practice Location Address Fax Number:
888-445-4263
Provider Enumeration Date:
10/11/2005

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: 225XH1200X , with the licence number:  3119 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Z113264 . This is a "MEDICARE GROUP" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 886260 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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