1235498536 NPI number — KYLIE JEANE BAUER FRIDERES MA

Table of content: KYLIE JEANE BAUER FRIDERES MA (NPI 1235498536)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235498536 NPI number — KYLIE JEANE BAUER FRIDERES MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRIDERES
Provider First Name:
KYLIE
Provider Middle Name:
JEANE BAUER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA
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:
1235498536
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
60748 RIVER BEND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97702-7909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-690-5264
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
731 NW FRANKLIN AVE STE 107
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-306-1128
Provider Business Practice Location Address Fax Number:
541-647-1162
Provider Enumeration Date:
05/08/2012

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: 101YM0800X , with the licence number:  C4603 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 123190 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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