1316099401 NPI number — THE EVERETT CLINIC, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316099401 NPI number — THE EVERETT CLINIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE EVERETT CLINIC, PLLC
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:
THE EVERETT CLINIC
Provider Other Organization Name Type Code:
3
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:
1316099401
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5127
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98206-5127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-259-0966
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3927 RUCKER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVERETT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98201-4833
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-259-0966
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RODEWALD
Authorized Official First Name:
ANDREA
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
425-339-5460

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  50D0662650 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7776503 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 33000 . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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