1013081058 NPI number — BOBODZHANOV INC

Table of content: (NPI 1013081058)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013081058 NPI number — BOBODZHANOV INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOBODZHANOV 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:
ULTRAECHO
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:
1013081058
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
440 W BRODERICK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83646-6427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-786-6936
Provider Business Mailing Address Fax Number:
206-621-4176

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
440 W BRODERICK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83646-6427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-786-6936
Provider Business Practice Location Address Fax Number:
206-621-4176
Provider Enumeration Date:
11/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BOBODZHANOV
Authorized Official First Name:
ALEXI
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT CEO
Authorized Official Telephone Number:
206-621-4722

Provider Taxonomy Codes

  • Taxonomy code: 246XS1301X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2471S1302X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2471V0105X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335V00000X , with the licence number: N/A PORTABLE U/S , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0185002 . This is a "LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7130BO . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 47001664 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7115389 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 568397002 . This is a "GROUP HEALTH COOPERATIVE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".