1891410676 NPI number — STACY RENAE KADOR

Table of content: STACY RENAE KADOR (NPI 1891410676)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891410676 NPI number — STACY RENAE KADOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KADOR
Provider First Name:
STACY
Provider Middle Name:
RENAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1891410676
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 748465
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-8465
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-284-7486
Provider Business Mailing Address Fax Number:
617-807-0958

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23410 GRAND RESERVE DR STE 301
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KATY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77494-4989
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-284-7483
Provider Business Practice Location Address Fax Number:
617-807-0958
Provider Enumeration Date:
10/05/2022

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: 101YP2500X , with the licence number:  89861 , 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)