1598019614 NPI number — KELSEY TEJADA COTA

Table of content: KELSEY TEJADA COTA (NPI 1598019614)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598019614 NPI number — KELSEY TEJADA COTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TEJADA
Provider First Name:
KELSEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
COTA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RATCLIFF
Provider Other First Name:
KELSEY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
COTA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1598019614
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3801 MAIN DR STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72704-6364
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-856-6400
Provider Business Mailing Address Fax Number:
479-856-6623

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2837 AMERICAN ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGDALE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72764-6927
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-365-7258
Provider Business Practice Location Address Fax Number:
479-365-7248
Provider Enumeration Date:
10/29/2012

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: 224Z00000X , with the licence number:  OT-A705 , 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)