1780646612 NPI number — MRS. KIMBERLY JEAN PORTER PAC

Table of content: MRS. KIMBERLY JEAN PORTER PAC (NPI 1780646612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780646612 NPI number — MRS. KIMBERLY JEAN PORTER PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTER
Provider First Name:
KIMBERLY
Provider Middle Name:
JEAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EVANS
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
JEAN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1780646612
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 CORPORATE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70508-3870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-893-9698
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
243 CURTISS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BARKSDALE AFB
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71110-2425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-456-7320
Provider Business Practice Location Address Fax Number:
318-456-6246
Provider Enumeration Date:
04/05/2006

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:  PA.200235 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1070445 . This is a "NCCPA" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com