1710992185 NPI number — LESLIE R BORNFLETH MD

Table of content: KASANDRA JARAMILLO (NPI 1356096879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710992185 NPI number — LESLIE R BORNFLETH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BORNFLETH
Provider First Name:
LESLIE
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1710992185
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
732 SUMMITVIEW AVE
Provider Second Line Business Mailing Address:
#621
Provider Business Mailing Address City Name:
YAKIMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98902-3032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-573-3448
Provider Business Mailing Address Fax Number:
509-574-4481

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 S 11TH AVE
Provider Second Line Business Practice Location Address:
SUITE 321
Provider Business Practice Location Address City Name:
YAKIMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98902-3242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-248-3954
Provider Business Practice Location Address Fax Number:
509-248-3955
Provider Enumeration Date:
07/31/2006

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: 207T00000X , with the licence number:  MD00014255 , 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: 8119208 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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