1730628223 NPI number — KELLEY O'DONNELL CAC III, ATP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730628223 NPI number — KELLEY O'DONNELL CAC III, ATP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'DONNELL
Provider First Name:
KELLEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CAC III, ATP
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:
1730628223
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4485 WADSWORTH BLVD
Provider Second Line Business Mailing Address:
SUITE 206
Provider Business Mailing Address City Name:
WHEAT RIDGE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80033-3310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-431-5664
Provider Business Mailing Address Fax Number:
303-431-6713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4485 WADSWORTH BLVD
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
WHEAT RIDGE
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80033-3310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-431-5664
Provider Business Practice Location Address Fax Number:
303-431-6713
Provider Enumeration Date:
02/16/2017

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: 101YA0400X , with the licence number:  ACC 0007129 , 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)

  • Identifier: ACC 0007129 . This is a "CAC LICENSE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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