1710795463 NPI number — KATRENA DEZERAI PALMER LAC

Table of content: KATRENA DEZERAI PALMER LAC (NPI 1710795463)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710795463 NPI number — KATRENA DEZERAI PALMER LAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PALMER
Provider First Name:
KATRENA
Provider Middle Name:
DEZERAI
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:
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:
1710795463
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1530
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILES CITY
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59301-1530
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-234-0234
Provider Business Mailing Address Fax Number:
406-234-0235

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 3RD ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLASGOW
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59230-2303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-228-9349
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/27/2024

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: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 71830 . This is a "LAC LICENSE" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".