1790950855 NPI number — KALEIDOSCOPE PEDIATRIC SPEECH THERAPY SPECIALISTS, LLC

Table of content: (NPI 1790950855)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790950855 NPI number — KALEIDOSCOPE PEDIATRIC SPEECH THERAPY SPECIALISTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KALEIDOSCOPE PEDIATRIC SPEECH THERAPY SPECIALISTS, LLC
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:
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Provider Other Middle Name:
Provider Other Name Prefix Text:
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NPI Number Information

NPI Number:
1790950855
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2536 W INDUSTRIAL PARK DR
Provider Second Line Business Mailing Address:
SUITE 7
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47404-2635
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-340-0265
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2536 W INDUSTRIAL PARK DR
Provider Second Line Business Practice Location Address:
SUITE 7
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47404-2635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-340-0265
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KILAR
Authorized Official First Name:
CAROLYN
Authorized Official Middle Name:
YANDURA
Authorized Official Title or Position:
SPEECH-LANGUAGE PATHOLOGIST
Authorized Official Telephone Number:
812-340-0265

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  22002743A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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