1720157233 NPI number — KRISTINE SUPPLE PA

Table of content: KRISTINE SUPPLE PA (NPI 1720157233)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720157233 NPI number — KRISTINE SUPPLE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUPPLE
Provider First Name:
KRISTINE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1720157233
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2705 LOMA VISTA RD
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
VENTURA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93003-1581
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-667-2801
Provider Business Mailing Address Fax Number:
805-641-1706

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2921 SAVIERS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OXNARD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93033-5314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-487-5588
Provider Business Practice Location Address Fax Number:
805-487-5589
Provider Enumeration Date:
11/07/2006

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:  15019 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: RHM08608F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: RHM18553H , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: RHM08609F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZT40394F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 95-1683892 . This is a "OTHER INSURANCE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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