1760811798 NPI number — SANDAL KELLY PHD

Table of content: TRAVIS TODD MCKENZIE D.O. (NPI 1386900595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760811798 NPI number — SANDAL KELLY PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANDAL KELLY PHD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1760811798
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6531 PLUM ORCHARD CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89142-0966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-255-0056
Provider Business Mailing Address Fax Number:
702-255-0076

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6531 PLUM ORCHARD CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89142-0966
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-255-0056
Provider Business Practice Location Address Fax Number:
702-255-0076
Provider Enumeration Date:
11/12/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KELLY
Authorized Official First Name:
SANDAL
Authorized Official Middle Name:
ARLILLIAN
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
702-255-0056

Provider Taxonomy Codes

  • Taxonomy code: 261QM1000X , with the licence number:  MFT 01002 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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