1770910663 NPI number — PINECONE HEIGHTS CORPORATION

Table of content: (NPI 1770910663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770910663 NPI number — PINECONE HEIGHTS CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINECONE HEIGHTS CORPORATION
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:
CREST MANOR AFH
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:
1770910663
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10541 SE 226TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98031-2621
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-940-1020
Provider Business Mailing Address Fax Number:
425-523-3990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1171 CAMAS AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RENTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98056-2918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-940-1020
Provider Business Practice Location Address Fax Number:
425-523-3990
Provider Enumeration Date:
10/09/2013

Additional Information

Authorized Official

Authorized Official Last Name:
HOLLIDAY
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
206-940-1020

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X , with the licence number:  752487 , 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: 320914 . This is a "CLIENT SERVICE CONTRACT" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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