1881204303 NPI number — KYLA SUE MCENTIRE OTR

Table of content: KYLA SUE MCENTIRE OTR (NPI 1881204303)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881204303 NPI number — KYLA SUE MCENTIRE OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCENTIRE
Provider First Name:
KYLA
Provider Middle Name:
SUE
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:
1881204303
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
305 NE LOOP 820
Provider Second Line Business Mailing Address:
BUSINESS TOWER 1, SUITE 200
Provider Business Mailing Address City Name:
HURST
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76053
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-292-8787
Provider Business Mailing Address Fax Number:
817-789-6849

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
921 SHILOH RD STE C110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75703-1406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-939-2800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/10/2020

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 , with the licence number:  103202 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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