1699966200 NPI number — KIMBERLY HENRICHON MEDOTR/L

Table of content: KIMBERLY HENRICHON MEDOTR/L (NPI 1699966200)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699966200 NPI number — KIMBERLY HENRICHON MEDOTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENRICHON
Provider First Name:
KIMBERLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MEDOTR/L
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:
1699966200
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 WEST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST HATFIELD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01088-9562
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-586-8200
Provider Business Mailing Address Fax Number:
413-582-1460

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4 WEST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST HATFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01088-9562
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-586-8200
Provider Business Practice Location Address Fax Number:
413-582-1460
Provider Enumeration Date:
08/08/2007

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: 225X00000X , with the licence number:  2466 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225XH1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 043527497 . This is a "GREATWEST" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 043527497 . This is a "CT CARE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 64-04290 . This is a "UHC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 972730 . This is a "NETWORK" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 043527497 . This is a "CIGNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 103355100 . This is a "DEPT OF LABOR" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 043527497 . This is a "NORTH REGION" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 043527497 . This is a "GIC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9715568 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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