1871698050 NPI number — RENA R GODFREY M.P.T.

Table of content: RENA R GODFREY M.P.T. (NPI 1871698050)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871698050 NPI number — RENA R GODFREY M.P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GODFREY
Provider First Name:
RENA
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.P.T.
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:
1871698050
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1519 132ND ST SE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98208-7203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-357-9380
Provider Business Mailing Address Fax Number:
425-357-9382

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 S CEDAR ST STE B1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405-2305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-272-6910
Provider Business Practice Location Address Fax Number:
253-383-4218
Provider Enumeration Date:
09/13/2006

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:  PT00005367 , 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: GO9746 . This is a "PREMERA BLUE CROSS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: P00286357 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: GO9746 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8341430 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0197667 . This is a "DEPT OF LABOR & INDUSTRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0296931 . This is a "L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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