1417937517 NPI number — VAUN J ARCHIBALD DO

Table of content: VAUN J ARCHIBALD DO (NPI 1417937517)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417937517 NPI number — VAUN J ARCHIBALD DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ARCHIBALD
Provider First Name:
VAUN
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1417937517
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3340 E GOLDSTONE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-1026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-367-5170
Provider Business Mailing Address Fax Number:
208-367-5180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1072 N LIBERTY ST
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83704-8708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-367-4321
Provider Business Practice Location Address Fax Number:
208-367-4525
Provider Enumeration Date:
01/17/2006

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: 2080A0000X , with the licence number:  O-0449 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: O-0449 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 807789500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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