1598273377 NPI number — KALEIGH S DE LA CRUZ NP

Table of content: KALEIGH S DE LA CRUZ NP (NPI 1598273377)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598273377 NPI number — KALEIGH S DE LA CRUZ NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE LA CRUZ
Provider First Name:
KALEIGH
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1598273377
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6701 BAUM DR
Provider Second Line Business Mailing Address:
STE 140
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37919-7361
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-584-5727
Provider Business Mailing Address Fax Number:
865-450-9904

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 BRIARCLIFF RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARNER ROBINS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31088-4039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-922-8900
Provider Business Practice Location Address Fax Number:
478-922-8989
Provider Enumeration Date:
01/16/2018

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: 363L00000X , with the licence number:  1776 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RP1001X , with the licence number: 049978GA , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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