1073939062 NPI number — PUGET SOUND KIDNEY CENTERS

Table of content: (NPI 1073939062)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073939062 NPI number — PUGET SOUND KIDNEY CENTERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PUGET SOUND KIDNEY CENTERS
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:
Provider Other Organization Name Type Code:
6
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:
1073939062
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1019 PACIFIC AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98201-4148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-259-5195
Provider Business Mailing Address Fax Number:
425-259-4860

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
809 31ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANACORTES
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-755-3586
Provider Business Practice Location Address Fax Number:
360-982-2693
Provider Enumeration Date:
03/14/2014

Additional Information

Authorized Official

Authorized Official Last Name:
KELLY
Authorized Official First Name:
HAROLD
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT AND CEO
Authorized Official Telephone Number:
425-259-5195

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  600401431 , 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: 50-2573 . This is a "MEDICARE ID-TYPE UNSPECIFIED" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2036232 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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