1336186444 NPI number — H KENNETH KOPOLOW O.D & ASSOC P.C

Table of content: (NPI 1336186444)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336186444 NPI number — H KENNETH KOPOLOW O.D & ASSOC P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
H KENNETH KOPOLOW O.D & ASSOC P.C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1336186444
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7361 W LAKE MEAD BLVD
Provider Second Line Business Mailing Address:
STE 104
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89128-1040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-733-6764
Provider Business Mailing Address Fax Number:
702-255-5797

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4300 MEADOWS LN
Provider Second Line Business Practice Location Address:
STE 126
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89107-3004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-733-6764
Provider Business Practice Location Address Fax Number:
702-614-6018
Provider Enumeration Date:
05/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KOPOLOW
Authorized Official First Name:
HARLAN
Authorized Official Middle Name:
KENNETH
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
702-733-6764

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  274 , 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)

  • Identifier: 100507862 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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