1609936707 NPI number — KINDRED LLC

Table of content: (NPI 1609936707)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609936707 NPI number — KINDRED LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KINDRED LLC
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:
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:
1609936707
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 NE GLEN OAK AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61603-4314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-673-0000
Provider Business Mailing Address Fax Number:
309-673-3730

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 NE GLEN OAK AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61603-4314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-673-0000
Provider Business Practice Location Address Fax Number:
309-673-3730
Provider Enumeration Date:
12/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KINDRED
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
309-673-0000

Provider Taxonomy Codes

  • Taxonomy code: 207VX0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9032024 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 204931 . This is a "PIN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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