1629374301 NPI number — YVONNE PEREZ KETTERING LAC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629374301 NPI number — YVONNE PEREZ KETTERING LAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KETTERING
Provider First Name:
YVONNE
Provider Middle Name:
PEREZ
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PEREZ
Provider Other First Name:
YVONNE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LAC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629374301
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8701 SHOAL CREEK BLVD
Provider Second Line Business Mailing Address:
SUITE 302
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78757-6864
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-801-2453
Provider Business Mailing Address Fax Number:
512-420-8573

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8701 SHOAL CREEK BLVD
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78757-6864
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-801-2453
Provider Business Practice Location Address Fax Number:
512-420-8573
Provider Enumeration Date:
01/28/2011

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: 171100000X , with the licence number:  TXAC00847 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 172M00000X , with the licence number: MT107098 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0031DG . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0944746-02 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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