1053550764 NPI number — MISS RENA JEANEEN RIDDELL L.M.P.

Table of content: MISS RENA JEANEEN RIDDELL L.M.P. (NPI 1053550764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053550764 NPI number — MISS RENA JEANEEN RIDDELL L.M.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RIDDELL
Provider First Name:
RENA
Provider Middle Name:
JEANEEN
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
L.M.P.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RIDDELL
Provider Other First Name:
RENA
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1053550764
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2501 SE MILE HILL DR
Provider Second Line Business Mailing Address:
STE. A-101
Provider Business Mailing Address City Name:
PORT ORCHARD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98366-3500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-540-1751
Provider Business Mailing Address Fax Number:
360-895-4210

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3061 SE MAPLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ORCHARD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98366-2945
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-540-1751
Provider Business Practice Location Address Fax Number:
360-895-4210
Provider Enumeration Date:
02/19/2009

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: 225700000X , with the licence number:  M60041452 , 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)





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