1336270578 NPI number — DR. VIRGINIA KAY KETTENBACH PT,PHD

Table of content: DR. VIRGINIA KAY KETTENBACH PT,PHD (NPI 1336270578)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336270578 NPI number — DR. VIRGINIA KAY KETTENBACH PT,PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KETTENBACH
Provider First Name:
VIRGINIA
Provider Middle Name:
KAY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PT,PHD
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:
1336270578
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1123 CHATELET DR.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FERGUSON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63135-1334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-977-8543
Provider Business Mailing Address Fax Number:
314-977-8513

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3437 CAROLINE ST., ROOM 1030
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST. LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-977-8543
Provider Business Practice Location Address Fax Number:
314-977-8513
Provider Enumeration Date:
03/08/2007

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:  RO313 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com