1346649894 NPI number — KIDS CARE MEDICAL CENTER

Table of content: (NPI 1346649894)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346649894 NPI number — KIDS CARE MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIDS CARE MEDICAL CENTER
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:
1346649894
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6073 MT MORIAH RD EXT
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38115-2666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-365-2555
Provider Business Mailing Address Fax Number:
901-365-2544

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6073 MT MORIAH RD EXT
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38115-2666
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-365-2555
Provider Business Practice Location Address Fax Number:
901-365-2544
Provider Enumeration Date:
08/21/2014

Additional Information

Authorized Official

Authorized Official Last Name:
COWAN
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
LANGSTON
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
901-365-2555

Provider Taxonomy Codes

  • Taxonomy code: 2080A0000X , with the licence number:  21143 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3896594 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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