1164897625 NPI number — MS. KEIGHLY GRACE COGAN RN

Table of content: MS. KEIGHLY GRACE COGAN RN (NPI 1164897625)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164897625 NPI number — MS. KEIGHLY GRACE COGAN RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COGAN
Provider First Name:
KEIGHLY
Provider Middle Name:
GRACE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KILSGAARD
Provider Other First Name:
KEIGHLY
Provider Other Middle Name:
GRACE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1164897625
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
261 E WILLOW ST
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90806-2637
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-735-6131
Provider Business Mailing Address Fax Number:
562-290-0251

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
261 E WILLOW ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90806-2637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-735-6131
Provider Business Practice Location Address Fax Number:
562-290-0251
Provider Enumeration Date:
12/09/2015

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: 163W00000X , with the licence number:  95034140 , 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)

  • Identifier: 33-0150193 . This is a "MEDI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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