1194973628 NPI number — MARYS CORNER MEDICAL CLINIC INC PS

Table of content: (NPI 1194973628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194973628 NPI number — MARYS CORNER MEDICAL CLINIC INC PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARYS CORNER MEDICAL CLINIC INC PS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MARYS CORNER MEDICAL CLINIC
Provider Other Organization Name Type Code:
4
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:
1194973628
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4254 JACKSON HWY.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHEHALIS
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98532
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-262-3966
Provider Business Mailing Address Fax Number:
360-262-3967

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4254 JACKSON HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHEHALIS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-262-3966
Provider Business Practice Location Address Fax Number:
360-262-3967
Provider Enumeration Date:
09/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
INGLIS
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
HOPE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
360-262-3966

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD00039760 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: OP00000823 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR1300X , with the licence number: OP00000823 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X , with the licence number: MD00039760 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X , with the licence number: AP30005675 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X , with the licence number: PA0004588 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA10004588 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: AP30005675 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 7132244 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7132764 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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