1699305730 NPI number — CALVIN ERNEST KETTERLING R.PH.

Table of content: CALVIN ERNEST KETTERLING R.PH. (NPI 1699305730)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699305730 NPI number — CALVIN ERNEST KETTERLING R.PH.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KETTERLING
Provider First Name:
CALVIN
Provider Middle Name:
ERNEST
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
R.PH.
Provider Gender Code:
M

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:
1699305730
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 751
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH VERNON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47265-0751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-592-6341
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2325 N STATE HIGHWAY 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH VERNON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47265-9251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-352-1780
Provider Business Practice Location Address Fax Number:
812-352-1782
Provider Enumeration Date:
01/16/2020

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: 1835P0018X , with the licence number:  26016439A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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