1831279710 NPI number — RENEE T TEDDER

Table of content: RENEE T TEDDER (NPI 1831279710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831279710 NPI number — RENEE T TEDDER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TEDDER
Provider First Name:
RENEE
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1831279710
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5210 CORPORATE CENTER LOOP SE
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
LACEY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98503-5952
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-455-8155
Provider Business Mailing Address Fax Number:
360-455-1655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 MARKET ST NE
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98501-1008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-754-7085
Provider Business Practice Location Address Fax Number:
360-754-3671
Provider Enumeration Date:
10/16/2006

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: 225100000X , with the licence number:  PT00009010 , 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: 1192TE . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 710883456-98516-A003 . This is a "TRICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 4939TE . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 710883456-98503-A009 . This is a "TRICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 6544TE . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 710883456-98501-A010 . This is a "TRICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8401820 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 710883456-98512-A008 . This is a "TRICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0219728 . This is a "DEPT. OF LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 5691TE . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 710883456-98502-A005 . This is a "TRICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7242925 . This is a "AETNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8493TE . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8944149 . This is a "L&I CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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