1700408390 NPI number — KETTLE CREEK OUTFITTERS LTD

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 1700408390 NPI number — KETTLE CREEK OUTFITTERS LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KETTLE CREEK OUTFITTERS LTD
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:
1700408390
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
88 QUIET OAKS CAMPGROUND LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CROSS FORK
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17729-9430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-502-2919
Provider Business Mailing Address Fax Number:
570-923-1799

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
88 QUIET OAKS CAMPGROUND LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROSS FORK
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17729-9430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-502-2919
Provider Business Practice Location Address Fax Number:
570-923-1799
Provider Enumeration Date:
05/18/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FLACK
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
RALPH
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
570-502-2919

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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