1679105530 NPI number — SHELBY KLOOSTERBOER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679105530 NPI number — SHELBY KLOOSTERBOER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLOOSTERBOER
Provider First Name:
SHELBY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1679105530
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
224-D CORNWALL STREET, NW, SUITE 403
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEESBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20176-2704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-737-6010
Provider Business Mailing Address Fax Number:
703-443-8643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
46440 BENEDICT DRIVE, SUITE 107
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STERLING
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20164-6602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-450-1125
Provider Business Practice Location Address Fax Number:
703-450-1145
Provider Enumeration Date:
02/10/2020

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 0110007652 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 30016389950001 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1679105530 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com