1346776127 NPI number — KELLI R LOVELAND AUD

Table of content: KELLI R LOVELAND AUD (NPI 1346776127)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346776127 NPI number — KELLI R LOVELAND AUD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOVELAND
Provider First Name:
KELLI
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AUD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REDER
Provider Other First Name:
KELLI
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1346776127
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5546
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80217-5546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-475-3481
Provider Business Mailing Address Fax Number:
801-475-3414

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1551 RENAISSANCE TOWNE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOUNTIFUL
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-295-5581
Provider Business Practice Location Address Fax Number:
801-295-9253
Provider Enumeration Date:
05/11/2017

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: 231H00000X , with the licence number:  10362664-4103 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1346776127 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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