1740460385 NPI number — KIMBERLY SUZANNE HOLT OTR

Table of content: KIMBERLY SUZANNE HOLT OTR (NPI 1740460385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740460385 NPI number — KIMBERLY SUZANNE HOLT OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLT
Provider First Name:
KIMBERLY
Provider Middle Name:
SUZANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR
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:
1740460385
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 SPANISH TRCE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SILSBEE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77656-8928
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-722-5437
Provider Business Mailing Address Fax Number:
409-722-5435

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8700 9TH AVE
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
PORT ARTHUR
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77642-8030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
409-722-5437
Provider Business Practice Location Address Fax Number:
409-722-5435
Provider Enumeration Date:
11/12/2007

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: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110218 . This is a "EXECUTIVE COUNCIL OT" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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