1063728707 NPI number — YAKIMA ORTHOTICS AND PROSTHETICS, PC

Table of content: (NPI 1063728707)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063728707 NPI number — YAKIMA ORTHOTICS AND PROSTHETICS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
YAKIMA ORTHOTICS AND PROSTHETICS, PC
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:
KITTITAS ORTHOTICS AND PROSTHETICS
Provider Other Organization Name Type Code:
5
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:
1063728707
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/29/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
313 S 9TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YAKIMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98902-3516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1206 N DOLARWAY RD
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
ELLENSBURG
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98926-8392
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-925-7700
Provider Business Practice Location Address Fax Number:
509-925-7707
Provider Enumeration Date:
08/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
LAMBERT
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
509-248-8040

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  602349936 , 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: 120244 . This is a "LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: W40472 . This is a "CHAMPUS TRICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: YA0282 . This is a "PREMERA BLUE CROSS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 9045675 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: YA0282 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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