1629630801 NPI number — KATHRYN VICTORIA FOLDS CO60904245

Table of content: KATHRYN VICTORIA FOLDS CO60904245 (NPI 1629630801)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629630801 NPI number — KATHRYN VICTORIA FOLDS CO60904245

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOLDS
Provider First Name:
KATHRYN
Provider Middle Name:
VICTORIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CO60904245
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:
1629630801
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2204 PACIFIC AVE N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98631-3300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-642-3787
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 BOARDWALK DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIDGELAND
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29936-7994
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-645-2770
Provider Business Practice Location Address Fax Number:
843-645-2771
Provider Enumeration Date:
07/08/2019

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: 101YA0400X , with the licence number:  CO60904245 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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