1780715318 NPI number — MRS. MARY JEANNE KINCAID RD, CDCES

Table of content: MRS. MARY JEANNE KINCAID RD, CDCES (NPI 1780715318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780715318 NPI number — MRS. MARY JEANNE KINCAID RD, CDCES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KINCAID
Provider First Name:
MARY
Provider Middle Name:
JEANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD, CDCES
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:
1780715318
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1025 OLD ORCHARD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARBOR SPRINGS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49740-8630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-659-9880
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
560 W. MITCHELL ST
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
PEROSKEY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49770-2278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-487-7158
Provider Business Practice Location Address Fax Number:
231-487-5985
Provider Enumeration Date:
03/07/2007

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: 133V00000X , with the licence number:  LD 1636 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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