1174290761 NPI number — MRS. RACHEL LYNNE BALLARD

Table of content: MRS. RACHEL LYNNE BALLARD (NPI 1174290761)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174290761 NPI number — MRS. RACHEL LYNNE BALLARD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALLARD
Provider First Name:
RACHEL
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
O'NEAL
Provider Other First Name:
RACHEL
Provider Other Middle Name:
LYNNE
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:
1174290761
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9751 US HIGHWAY 52 S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLARKS HILL
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47930-9207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-418-7272
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3067 E WARM SPRINGS RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89120-3750
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-710-0000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/23/2021

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: 390200000X , with the licence number:  PI028 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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