Tequila Breyonda Petty, is a medicare enrolled "Occupational Therapist" provider in Kings Mountain, North Carolina. Her current practice location is
502 W King St, Kings Mountain, North Carolina. You can reach out to her office (for appointments etc.) via phone at
(855) 983-0488.
Tequila Breyonda Petty is licensed to practice in North Carolina (license number 16408) and she also participates in the medicare program. She does not accept medicare assignments directly but she may accept medicare through third-party (refer to Reassignment section below) and may also prescribe medicare part D drugs. Her NPI Number is 1417723768.
Healthcare Provider's Profile
| Full Name | Tequila Breyonda Petty |
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| Gender | Female |
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| Speciality | Occupational Therapist |
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| Location | 502 W King St, Kings Mountain, North Carolina |
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| Accepts Medicare Assignments | Medicare enrolled and may accept medicare through third-party reassignment. May prescribe medicare part D drugs. |
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NPI Data:
- NPI Number: 1417723768
- Provider Enumeration Date: 11/28/2023
- Last Update Date: 11/28/2023
Medicare PECOS Information:
- PECOS PAC ID: 3375995798
- Enrollment ID: I20240122000521
Medical Identifiers
Medical identifiers for Tequila Breyonda Petty such as npi, medicare ID, medicare PIN, medicaid, etc.
| Identifier | Type | State | Issuer |
|---|
| 1417723768 | NPI | - | NPPES |
Medical Taxonomies and Licenses
| Taxonomy | Type | License (State) | Status |
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| 225X00000X | Occupational Therapist | 16408 (North Carolina) | Primary |
Medicare Reassignments
Some practitioners may not bill the customers directly but medicare billing happens through clinics / group practice / hospitals where the provider works. Medicare reassignment of benefits is a mechanism by which practitioners allow third parties to bill and receive payment for medicare services performed by them. Tequila Breyonda Petty allows following entities to bill medicare on her behalf.
| Provider Name | Kidology Inc |
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| Provider Type | Part B Supplier - Clinic/group Practice |
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| Provider Identifiers | NPI Number: 1730591991
PECOS PAC ID: 3476943887
Enrollment ID: O20211129001112 |
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Medicare Part D Prescriber Enrollment
Any physician or other eligible professional who prescribes Part D drugs must either enroll in the Medicare program or opt out in order to prescribe drugs to their patients with Part D prescription drug benefit plans. Tequila Breyonda Petty is
enrolled with medicare and thus, if eligible, can prescribe medicare part D drugs to patients with medicare part D benefits.
Mailing Address and Practice Location
| Mailing Address | Practice Location Address |
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Tequila Breyonda Petty,
1039 W Chapel Rd,
Asheville, NC 28803-1634
Ph: (828) 423-4104 | Tequila Breyonda Petty,
502 W King St,
Kings Mountain, NC 28086-3362
Ph: (855) 983-0488 |
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