1457303695 NPI number — MR. KELLY LON DREVECKY OT R/L

Table of content: MR. KELLY LON DREVECKY OT R/L (NPI 1457303695)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457303695 NPI number — MR. KELLY LON DREVECKY OT R/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DREVECKY
Provider First Name:
KELLY
Provider Middle Name:
LON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
OT R/L
Provider Gender Code:
M

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:
1457303695
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 HARMONY ST NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINOT
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58703-2892
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-720-5355
Provider Business Mailing Address Fax Number:
701-839-1311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 HARMONY ST NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINOT
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58703-2892
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-720-5355
Provider Business Practice Location Address Fax Number:
701-839-1311
Provider Enumeration Date:
05/16/2006

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: 225X00000X , with the licence number:  612 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225XN1300X , with the licence number: 612 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225XP0200X , with the licence number: 612 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 50609 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".