1972963262 NPI number — KELLY BYRER

Table of content: MR. LANCE WAYNE WALCOTT CASE MANAGER (NPI 1942890470)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972963262 NPI number — KELLY BYRER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BYRER
Provider First Name:
KELLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1972963262
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7850 MISSION CENTER CT
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92108-1322
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-578-2232
Provider Business Mailing Address Fax Number:
619-578-2231

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
861 HAROLD PL
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91914-4553
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-578-2232
Provider Business Practice Location Address Fax Number:
619-578-2231
Provider Enumeration Date:
02/29/2016

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: 2355S0801X , with the licence number:  SPA 3664 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 330965547 . This is a "ADDIE'S AUTISM FITT CLUB" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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