1285656348 NPI number — MRS. KIMBERLY BASS FREDERICKS BS

Table of content: MRS. KIMBERLY BASS FREDERICKS BS (NPI 1285656348)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285656348 NPI number — MRS. KIMBERLY BASS FREDERICKS BS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREDERICKS
Provider First Name:
KIMBERLY
Provider Middle Name:
BASS
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BASS
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
VINET
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
BS
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1285656348
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:
8118 GEORGIA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GULFPORT
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39501-7541
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-868-1378
Provider Business Mailing Address Fax Number:
228-523-4675

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 VETERANS AVE
Provider Second Line Business Practice Location Address:
(116B)
Provider Business Practice Location Address City Name:
BILOXI
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39531-2410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-523-4241
Provider Business Practice Location Address Fax Number:
228-523-4675
Provider Enumeration Date:
07/24/2006

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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