1710178041 NPI number — JUSTIN M MAUGHAN CPO

Table of content: JUSTIN M MAUGHAN CPO (NPI 1710178041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710178041 NPI number — JUSTIN M MAUGHAN CPO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAUGHAN
Provider First Name:
JUSTIN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CPO
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:
1710178041
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1546
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAHAM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98338-1546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-447-0770
Provider Business Mailing Address Fax Number:
253-875-7768

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9220 RIDGETOP BLVD NW
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
SILVERDALE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98383-8556
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-698-2229
Provider Business Practice Location Address Fax Number:
360-698-0122
Provider Enumeration Date:
08/01/2007

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: 222Z00000X , with the licence number:  OI00000326 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 224P00000X , with the licence number: PS00000183 , 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: 8371569 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com