1639211725 NPI number — KELLY TODD FLEMETAKIS MOT

Table of content: KELLY TODD FLEMETAKIS MOT (NPI 1639211725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639211725 NPI number — KELLY TODD FLEMETAKIS MOT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FLEMETAKIS
Provider First Name:
KELLY
Provider Middle Name:
TODD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MOT
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:
1639211725
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16635 168TH PL NE
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
WOODINVILLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98072-8988
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-683-4928
Provider Business Mailing Address Fax Number:
425-481-3332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16635 168TH PL NE
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
WOODINVILLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98072-8988
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-683-4928
Provider Business Practice Location Address Fax Number:
425-481-3332
Provider Enumeration Date:
02/13/2007

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: 225XP0200X , with the licence number:  OT00003368 , 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)

  • Identifier: 3153FL . This is a "REGENCE PROVIDER NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 351452100000 . This is a "PREMERA PROVIDER NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 743167413 . This is a "TAX IDENTIFICATION NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7683683 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0007633803 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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