1376991083 NPI number — KELLEY K HAGA L.P.T.A., A.T.C.

Table of content: KELLEY K HAGA L.P.T.A., A.T.C. (NPI 1376991083)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376991083 NPI number — KELLEY K HAGA L.P.T.A., A.T.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAGA
Provider First Name:
KELLEY
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.P.T.A., A.T.C.
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:
1376991083
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
624 MUSSERS MILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CROCKETT
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24323-3039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-686-5491
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1152 SNIDER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24354-4216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-782-9696
Provider Business Practice Location Address Fax Number:
276-782-9886
Provider Enumeration Date:
06/03/2016

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: 225200000X , with the licence number:  2306601430 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2255A2300X , with the licence number: 0126000330 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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