Provider Demographics
NPI:1083193841
Name:UPCHURCH, KI
Entity Type:Individual
Prefix:
First Name:KI
Middle Name:
Last Name:UPCHURCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19656 US HIGHWAY 271
Mailing Address - Street 2:
Mailing Address - City:SPIRO
Mailing Address - State:OK
Mailing Address - Zip Code:74959-4454
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3514 COUNTRY CLUB AVE STE 6
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3300
Practice Address - Country:US
Practice Address - Phone:918-649-8023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-11
Last Update Date:2018-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies