1659400653 NPI number — KEDR LLC

Table of content: (NPI 1659400653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659400653 NPI number — KEDR LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEDR 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:
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:
1659400653
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:
4080 N BROOKFIELD RD STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53045-7445
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-781-0084
Provider Business Mailing Address Fax Number:
262-781-0090

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4080 N BROOKFIELD RD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53045-7445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-781-0084
Provider Business Practice Location Address Fax Number:
262-781-0090
Provider Enumeration Date:
03/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
EBNER
Authorized Official First Name:
KINGA
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
262-781-0084

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3547-012 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 38937200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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