1689887580 NPI number — DERONDA KAY BACK RPH

Table of content: DERONDA KAY BACK RPH (NPI 1689887580)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689887580 NPI number — DERONDA KAY BACK RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BACK
Provider First Name:
DERONDA
Provider Middle Name:
KAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RPH
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:
1689887580
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 931
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41339-0931
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-666-7060
Provider Business Mailing Address Fax Number:
606-666-9454

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
842 HWY 15 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-666-7060
Provider Business Practice Location Address Fax Number:
606-666-9454
Provider Enumeration Date:
05/07/2007

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: 183500000X , with the licence number:  008355 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 008355 . This is a "KY STATE LICENSE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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