1003380049 NPI number — KIMBERLY VERMILLION FOGARTY JD, MA, BC-TMH

Table of content: KIMBERLY VERMILLION FOGARTY JD, MA, BC-TMH (NPI 1003380049)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003380049 NPI number — KIMBERLY VERMILLION FOGARTY JD, MA, BC-TMH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOGARTY
Provider First Name:
KIMBERLY
Provider Middle Name:
VERMILLION
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
JD, MA, BC-TMH
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:
1003380049
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8 PACIFICO
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAGUNA NIGUEL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92677-4242
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-422-5885
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
580 BROADWAY ST STE 208
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAGUNA BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92651-4311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-424-9755
Provider Business Practice Location Address Fax Number:
949-488-0344
Provider Enumeration Date:
01/13/2019

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: 106H00000X , with the licence number:  1600014 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: 89459 , 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)





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