1770811903 NPI number — KAYLA R LICARI P.A.-C

Table of content: KAYLA R LICARI P.A.-C (NPI 1770811903)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770811903 NPI number — KAYLA R LICARI P.A.-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LICARI
Provider First Name:
KAYLA
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MYERS
Provider Other First Name:
KAYLA
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
P-A.-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770811903
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3700 52ND ST SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49512-9637
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-656-3700
Provider Business Mailing Address Fax Number:
616-656-3701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3700 52ND ST SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49512-9637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-656-3700
Provider Business Practice Location Address Fax Number:
616-656-3701
Provider Enumeration Date:
11/30/2009

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: 363AM0700X , with the licence number:  5601005659 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5601005659 . This is a "STATE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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