1497975411 NPI number — MAURICE K. KPEGLO

Table of content: (NPI 1497975411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497975411 NPI number — MAURICE K. KPEGLO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAURICE K. KPEGLO
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1497975411
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 14914
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27415-4914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-378-0760
Provider Business Mailing Address Fax Number:
336-378-0970

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2025 MARTIN L. KING JR DR.
Provider Second Line Business Practice Location Address:
SUITE-E
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27406-3334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-378-0760
Provider Business Practice Location Address Fax Number:
336-378-0970
Provider Enumeration Date:
05/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KPEGLO
Authorized Official First Name:
MAURICE
Authorized Official Middle Name:
KOBLA
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
336-378-0760

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  200001360016 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: 29314 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8950296 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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