1669428876 NPI number — KELLY A CLINTON PAC

Table of content: KELLY A CLINTON PAC (NPI 1669428876)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669428876 NPI number — KELLY A CLINTON PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLINTON
Provider First Name:
KELLY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
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:
1669428876
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5445 CARUTH HAVEN LN
Provider Second Line Business Mailing Address:
APT 924
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75225-8143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-797-7947
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4001 W 15TH ST
Provider Second Line Business Practice Location Address:
SUITE 225
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75093-5841
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-599-2559
Provider Business Practice Location Address Fax Number:
972-599-1226
Provider Enumeration Date:
05/26/2006

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: 363A00000X , with the licence number:  PA04635 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 280826302 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8Y0105 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 280826303 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1067023 . This is a "NCCPA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P01057828 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 280826301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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