1912515933 NPI number — LAUREN KONGKEOVIMAN LVN

Table of content: LORRIE CAPETILLO ATC, LAT (NPI 1023492311)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912515933 NPI number — LAUREN KONGKEOVIMAN LVN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KONGKEOVIMAN
Provider First Name:
LAUREN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LVN
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:
1912515933
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1090 E CYPRESS AVE STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REDDING
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96002-1163
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-223-2332
Provider Business Mailing Address Fax Number:
530-223-4721

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1850 WALNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RED BLUFF
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96080-3611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-527-6824
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/15/2020

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: 164X00000X , with the licence number:  696508 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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