1770139198 NPI number — MISS REBECCA LYNN KLOSOWSKI HIS

Table of content: MISS REBECCA LYNN KLOSOWSKI HIS (NPI 1770139198)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770139198 NPI number — MISS REBECCA LYNN KLOSOWSKI HIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLOSOWSKI
Provider First Name:
REBECCA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
HIS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KLOSOWSKI
Provider Other First Name:
BECKY
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
HIS
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1770139198
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 HENDERSON ST APT 346
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76102-4567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-793-2103
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 E LAMAR BLVD STE 624
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76006-7346
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-251-0577
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/12/2019

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: 237700000X , with the licence number:  80582 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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