1871618108 NPI number — MRS. KAREN MALOTT GACNIK M.S. CCC-A

Table of content: MRS. KAREN MALOTT GACNIK M.S. CCC-A (NPI 1871618108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871618108 NPI number — MRS. KAREN MALOTT GACNIK M.S. CCC-A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GACNIK
Provider First Name:
KAREN
Provider Middle Name:
MALOTT
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.S. CCC-A
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:
1871618108
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
712 FORTINO BLVD
Provider Second Line Business Mailing Address:
STE. D
Provider Business Mailing Address City Name:
PUEBLO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81008-2084
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-542-1760
Provider Business Mailing Address Fax Number:
179-542-5115

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
712 FORTINO BLVD
Provider Second Line Business Practice Location Address:
STE. D
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81008-2084
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-542-1760
Provider Business Practice Location Address Fax Number:
179-542-5115
Provider Enumeration Date:
03/19/2007

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: 231HA2400X , with the licence number:  471 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00200291 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".




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