1225444201 NPI number — MR. KIRK DOUGLAS KELLY

Table of content: MR. KIRK DOUGLAS KELLY (NPI 1225444201)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225444201 NPI number — MR. KIRK DOUGLAS KELLY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
KIRK
Provider Middle Name:
DOUGLAS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1225444201
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1931 CENTER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERKELEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94704-1105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-613-0770
Provider Business Mailing Address Fax Number:
510-666-0987

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1931 CENTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERKELEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94704-1105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-613-0770
Provider Business Practice Location Address Fax Number:
510-666-0987
Provider Enumeration Date:
07/10/2014

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: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00 . This is a "00" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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