1578773065 NPI number — MRS. KERRY LEE SARVIS MS, ATC, CSCS, FMSC

Table of content: MRS. KERRY LEE SARVIS MS, ATC, CSCS, FMSC (NPI 1578773065)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578773065 NPI number — MRS. KERRY LEE SARVIS MS, ATC, CSCS, FMSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SARVIS
Provider First Name:
KERRY
Provider Middle Name:
LEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS, ATC, CSCS, FMSC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WINGARDNER
Provider Other First Name:
KERRY
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578773065
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/02/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 WARREN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT POLK
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71459-3108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-574-6854
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 WARREN CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT POLK
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71459-3108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-574-6854
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2007

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: 2255A2300X , with the licence number:  AT002181 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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