1073667200 NPI number — MRS. HOLLI RAE KENLEY M.A.

Table of content: MRS. HOLLI RAE KENLEY M.A. (NPI 1073667200)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073667200 NPI number — MRS. HOLLI RAE KENLEY M.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENLEY
Provider First Name:
HOLLI
Provider Middle Name:
RAE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.A.
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:
1073667200
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35596 BUTTERFLY PEAK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNTAIN CENTER
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92561-3067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-397-7978
Provider Business Mailing Address Fax Number:
760-564-0300

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
78150 CALLE TAMPICO
Provider Second Line Business Practice Location Address:
SUITE 207A
Provider Business Practice Location Address City Name:
LA QUINTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92253-2907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-397-7978
Provider Business Practice Location Address Fax Number:
760-564-0300
Provider Enumeration Date:
01/23/2007

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:  MFC39156 , 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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