1346410321 NPI number — CAROL KLETT VANCE MD, INC.

Table of content: (NPI 1346410321)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346410321 NPI number — CAROL KLETT VANCE MD, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAROL KLETT VANCE MD, 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:
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:
1346410321
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1619 CURLEW DR
Provider Second Line Business Mailing Address:
SUITE 6
Provider Business Mailing Address City Name:
AMMON
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83406-4719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-523-4688
Provider Business Mailing Address Fax Number:
208-523-4990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1619 CURLEW DR
Provider Second Line Business Practice Location Address:
SUITE 6
Provider Business Practice Location Address City Name:
AMMON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83406-4719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-523-4688
Provider Business Practice Location Address Fax Number:
208-523-4990
Provider Enumeration Date:
03/06/2008

Additional Information

Authorized Official

Authorized Official Last Name:
VANCE
Authorized Official First Name:
CAROL
Authorized Official Middle Name:
KLETT
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
208-523-4688

Provider Taxonomy Codes

  • Taxonomy code: 2080P0008X , with the licence number:  M9751 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 807573500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2618808087 . This is a "CIGNA" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010158422 . This is a "REGENCE BLUESHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: B6254 . This is a "BCBS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 123868000 . This is a "WYOMING MEDICAID" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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