1710319199 NPI number — MRS. KIMBERLY RUTH SPENCER PARKS PTA

Table of content: MRS. KIMBERLY RUTH SPENCER PARKS PTA (NPI 1710319199)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710319199 NPI number — MRS. KIMBERLY RUTH SPENCER PARKS PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARKS
Provider First Name:
KIMBERLY
Provider Middle Name:
RUTH SPENCER
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PTA
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:
1710319199
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8725 DIGITAL DR
Provider Second Line Business Mailing Address:
APT 302
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28262-4384
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-404-7454
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8725 DIGITAL DR
Provider Second Line Business Practice Location Address:
APT 302
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28262-4384
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-404-7454
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/07/2013

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: 225200000X , with the licence number:  5141 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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