1760473805 NPI number — DR. KERRIE LYNN PADILLA O.D.

Table of content: DR. KERRIE LYNN PADILLA O.D. (NPI 1760473805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760473805 NPI number — DR. KERRIE LYNN PADILLA O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PADILLA
Provider First Name:
KERRIE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOSLEY
Provider Other First Name:
KERRIE
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760473805
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2817 REILLY ROAD MCXC COD CREDENTIALS
Provider Second Line Business Mailing Address:
WOMACK ARMY MEDICAL CENTER
Provider Business Mailing Address City Name:
FORT BRAGG
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28310-8952
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-907-8922
Provider Business Mailing Address Fax Number:
910-907-6069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
WOMACK ARMY MEDICAL CTR
Provider Second Line Business Practice Location Address:
JOEL HEALTH CLINIC OPTOMETRY LOGISTICS RD
Provider Business Practice Location Address City Name:
FORT BRAGG
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28310-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-907-6587
Provider Business Practice Location Address Fax Number:
910-643-2432
Provider Enumeration Date:
10/28/2005

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: 152W00000X , with the licence number:  2003018486 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 2398 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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