1477522811 NPI number — KAREN KORZELIUS

Table of content: (NPI 1477522811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477522811 NPI number — KAREN KORZELIUS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KAREN KORZELIUS
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:
SENSORY PLAYGROUND OT CLINIC
Provider Other Organization Name Type Code:
3
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:
1477522811
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50042 HORSESHOE TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBEMARLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28001-7628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-986-2472
Provider Business Mailing Address Fax Number:
704-986-2472

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24807 S BUSINESS 52
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBEMARLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28001-8180
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-796-5493
Provider Business Practice Location Address Fax Number:
704-986-2472
Provider Enumeration Date:
03/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KORZELIUS
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
Authorized Official Title or Position:
SOLE PRORPIETOR
Authorized Official Telephone Number:
704-796-5493

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7301373 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 128FY . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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