1144305350 NPI number — LUCIE KHADDURI BSPT

Table of content: LUCIE KHADDURI BSPT (NPI 1144305350)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144305350 NPI number — LUCIE KHADDURI BSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KHADDURI
Provider First Name:
LUCIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BSPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROMERO
Provider Other First Name:
LUCIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
BSPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1144305350
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-296-2223
Provider Business Mailing Address Fax Number:
630-759-9510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3015 LIMITED LN NW
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98502-2638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-709-0700
Provider Business Practice Location Address Fax Number:
360-709-0703
Provider Enumeration Date:
10/26/2006

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: 225100000X , with the licence number:  PT00008806 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0291092 . This is a "DEPT. OF LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 650023899 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8542KH . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8336786 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8936913 . This is a "CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 160515 . This is a "DEPT OF LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: A008 . This is a "TRICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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