=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427362946
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATE SELSBY REVILL DPM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2010
-----------------------------------------------------
Last Update Date | 12/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 407 NE 76TH TER
-----------------------------------------------------
City | GLADSTONE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64118-1708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-436-7900
-----------------------------------------------------
Fax | 816-436-0999
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18080 BEACH BLVD 103
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92648-1343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-596-8800
-----------------------------------------------------
Fax | 714-596-8889
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 2013035885
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------