1619202306 NPI number — OLD HENRY FAMILY PRACTICE, PLLC

Table of content: (NPI 1619202306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619202306 NPI number — OLD HENRY FAMILY PRACTICE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OLD HENRY FAMILY PRACTICE, PLLC
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:
1619202306
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2503 BUSH RIDGE DR
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40245-5885
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-245-2701
Provider Business Mailing Address Fax Number:
502-290-2839

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2503 BUSH RIDGE DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40245-5885
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-245-2701
Provider Business Practice Location Address Fax Number:
502-290-2839
Provider Enumeration Date:
10/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GUPTA
Authorized Official First Name:
RICHA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
502-295-8141

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





Copyright © 2007-2024 www.npivalidator.com