1861622300 NPI number — MRS. ANDREA D KEYS LADC

Table of content: MRS. ANDREA D KEYS LADC (NPI 1861622300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861622300 NPI number — MRS. ANDREA D KEYS LADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEYS
Provider First Name:
ANDREA
Provider Middle Name:
D
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LADC
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:
1861622300
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6000 BASS LAKE ROAD
Provider Second Line Business Mailing Address:
SUITE #201
Provider Business Mailing Address City Name:
CRYSTAL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55429-2794
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-578-7901
Provider Business Mailing Address Fax Number:
612-600-6956

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6000 BASS LAKE ROAD
Provider Second Line Business Practice Location Address:
SUITE #201
Provider Business Practice Location Address City Name:
CRYSTAL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-578-7901
Provider Business Practice Location Address Fax Number:
612-600-6956
Provider Enumeration Date:
07/17/2009

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: 101YA0400X , with the licence number:  302219 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 302219 . This is a "LICENSE NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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