1962411900 NPI number — PARKO INC

Table of content: (NPI 1962411900)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962411900 NPI number — PARKO INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PARKO INC
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:
MAC MEDICAL SHOP
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:
1962411900
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
228 NE 3RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCMINNVILLE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97128-4819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-472-2147
Provider Business Mailing Address Fax Number:
503-437-9206

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
228 NE 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCMINNVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97128-4819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-472-2147
Provider Business Practice Location Address Fax Number:
503-437-9206
Provider Enumeration Date:
08/07/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WINNEN
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
PATRICE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
503-472-2147

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 269216 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".