1710258579 NPI number — KELLEY L REBERRY PAC

Table of content: KELLEY L REBERRY PAC (NPI 1710258579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710258579 NPI number — KELLEY L REBERRY PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REBERRY
Provider First Name:
KELLEY
Provider Middle Name:
L
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:
1710258579
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 RAMPART WAY
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
DENVER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80230-6429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-858-7600
Provider Business Mailing Address Fax Number:
720-858-7610

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 RAMPART WAY
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
DENVER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80230-6429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-858-7600
Provider Business Practice Location Address Fax Number:
720-858-7610
Provider Enumeration Date:
01/25/2012

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:  2111 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 3760 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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