1346708716 NPI number — ROSEMARY THAIR KELLS LPC

Table of content: ROSEMARY THAIR KELLS LPC (NPI 1346708716)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346708716 NPI number — ROSEMARY THAIR KELLS LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLS
Provider First Name:
ROSEMARY
Provider Middle Name:
THAIR
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
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:
1346708716
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4680
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KETCHUM
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83340-4697
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-928-7181
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
141 CITATION WAY UNIT 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAILEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83333-5104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-788-0146
Provider Business Practice Location Address Fax Number:
208-788-1210
Provider Enumeration Date:
03/05/2019

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:  LPC-3954 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1942301106 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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