1639264427 NPI number — KERRY A OKELBERRY O D P C

Table of content: (NPI 1639264427)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639264427 NPI number — KERRY A OKELBERRY O D P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KERRY A OKELBERRY O D P C
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:
6
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:
1639264427
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6705 REDWOOD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST JORDAN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84084-2402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-268-0866
Provider Business Mailing Address Fax Number:
801-268-2092

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6705 REDWOOD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST JORDAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84084-2402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-268-0866
Provider Business Practice Location Address Fax Number:
801-268-2092
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OKELBERRY
Authorized Official First Name:
KERRY
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
801-268-0866

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  1125139934 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 528904440008 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: DR3610 . This is a "RETIRED RAILROAD MEDICARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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