1114079878 NPI number — MR. DARREL SIDES CSA

Table of content: MR. DARREL SIDES CSA (NPI 1114079878)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114079878 NPI number — MR. DARREL SIDES CSA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIDES
Provider First Name:
DARREL
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CSA
Provider Gender Code:
M

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:
1114079878
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:
PO BOX 583
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDEPENDENCE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41051-0583
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-816-6684
Provider Business Mailing Address Fax Number:
859-356-0682

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6271 MARTYS TRAIL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41051-0583
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-816-6684
Provider Business Practice Location Address Fax Number:
859-356-0682
Provider Enumeration Date:
01/16/2007

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: 363AS0400X , with the licence number:  SA109 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000308821 . This is a "BC" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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