1013309780 NPI number — KELLEY PACILLO OTR/L

Table of content: KELLEY PACILLO OTR/L (NPI 1013309780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013309780 NPI number — KELLEY PACILLO OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PACILLO
Provider First Name:
KELLEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BERNARD
Provider Other First Name:
KELLEY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1013309780
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
251 JOHNSTON ST SE STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35601-2515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-340-9708
Provider Business Mailing Address Fax Number:
256-340-9624

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1412 N BRINDLEE MOUNTAIN PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARAB
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35016-5431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-931-2013
Provider Business Practice Location Address Fax Number:
256-931-2014
Provider Enumeration Date:
03/04/2015

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:  3961 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1003819608 . This is a "GROUP NPI" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 529917620 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".