1588700801 NPI number — DR. WARREN L WHITNAH

Table of content: DR. WARREN L WHITNAH (NPI 1588700801)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588700801 NPI number — DR. WARREN L WHITNAH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITNAH
Provider First Name:
WARREN
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1588700801
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35555 SPARTA LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97870-6650
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-893-6012
Provider Business Mailing Address Fax Number:
541-893-6787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PINE EAGLE CLINIC
Provider Second Line Business Practice Location Address:
218 N. PINE STREET
Provider Business Practice Location Address City Name:
HALFWAY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97870
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-742-6012
Provider Business Practice Location Address Fax Number:
541-742-6013
Provider Enumeration Date:
01/30/2007

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: 122300000X , with the licence number:  4377 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4377 . This is a "DENTAL LICENSE #" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 0636682-6 . This is a "SID#" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 210013 . This is a "OMAP PROVIDER #" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 356545 . This is a "DRIVERS LICENSE #" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".