1346976032 NPI number — KELSEY KATE IDOM DPT

Table of content: KELSEY KATE IDOM DPT (NPI 1346976032)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346976032 NPI number — KELSEY KATE IDOM DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IDOM
Provider First Name:
KELSEY
Provider Middle Name:
KATE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OSBON
Provider Other First Name:
KELSEY
Provider Other Middle Name:
KATE
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:
1346976032
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
206 HENDERSON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71291-9409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1603 GOODWIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUSTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71270-2907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-255-7550
Provider Business Practice Location Address Fax Number:
318-255-7552
Provider Enumeration Date:
07/26/2022

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: 225100000X , with the licence number:  11173 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 11173 . This is a "LOUISIANA BOARD OF PHYSICAL THERAPY" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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