1528255874 NPI number — SUSAN ELLEN KUDLICK

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528255874 NPI number — SUSAN ELLEN KUDLICK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KUDLICK
Provider First Name:
SUSAN
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1528255874
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44900 60TH ST. WEST, RM 307
Provider Second Line Business Mailing Address:
HIGH DESERT HEALTH SYSTEM
Provider Business Mailing Address City Name:
LANCASTER
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93536
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-524-2493
Provider Business Mailing Address Fax Number:
661-524-2495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1529 E PALMDALE BLVD STE 150
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALMDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93550-2038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-575-1800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/01/2007

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: 106H00000X , with the licence number:  MFC47881 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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