1407355498 NPI number — KAYLA A HUERTA LAT, ATC

Table of content: KAYLA A HUERTA LAT, ATC (NPI 1407355498)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407355498 NPI number — KAYLA A HUERTA LAT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HUERTA
Provider First Name:
KAYLA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LAT, ATC
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:
1407355498
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 W ROCK PLACE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53209
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:
285 FOREST GROVE DR STE 207
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53072-3738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-732-2262
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/06/2018

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: 2255A2300X , with the licence number:  1721-39 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 22 . This is a "RESPIRATORY,REHABILITATIVE & RESTORATIVE SERVICE PROVIDER" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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