1104020148 NPI number — MR. DENNIS JEROME TEMBREULL H.I.S

Table of content: JACOBUS BOGAARDS (NPI 1164438495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104020148 NPI number — MR. DENNIS JEROME TEMBREULL H.I.S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TEMBREULL
Provider First Name:
DENNIS
Provider Middle Name:
JEROME
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
H.I.S
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1104020148
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1402 WILLIAMS AVE NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORTING
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98360-8468
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-535-6386
Provider Business Mailing Address Fax Number:
253-535-9723

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16007 56TH AVENUE CT E
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98375-9004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-535-6386
Provider Business Practice Location Address Fax Number:
253-535-9723
Provider Enumeration Date:
06/13/2007

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: 237700000X , with the licence number:  2602 , 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: 0190385 . This is a "LABOR AND INDUSTRIES PROV" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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