1710429840 NPI number — SEAN O'KELLEY DPT

Table of content: SEAN O'KELLEY DPT (NPI 1710429840)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710429840 NPI number — SEAN O'KELLEY DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'KELLEY
Provider First Name:
SEAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
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:
1710429840
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4220 132ND ST SE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
MILL CREEK
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98012-8999
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-316-8046
Provider Business Mailing Address Fax Number:
425-338-9637

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 110TH AVE NE
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
BELLEVUE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98004-5828
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-628-2072
Provider Business Practice Location Address Fax Number:
425-341-9056
Provider Enumeration Date:
11/07/2016

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: 225100000X , with the licence number:  PT60693079 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0364872 . This is a "L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0364848 . This is a "L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0364857 . This is a "L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0368033 . This is a "L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0364873 . This is a "L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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