1104048453 NPI number — MRS. DARLA SUE CARBAUGH PT

Table of content: MRS. DARLA SUE CARBAUGH PT (NPI 1104048453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104048453 NPI number — MRS. DARLA SUE CARBAUGH PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARBAUGH
Provider First Name:
DARLA
Provider Middle Name:
SUE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMITH
Provider Other First Name:
DARLA
Provider Other Middle Name:
SUE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104048453
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 145
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98356-0145
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-496-0087
Provider Business Mailing Address Fax Number:
360-496-0078

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 C WESTLAKE AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98356-0145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-496-0087
Provider Business Practice Location Address Fax Number:
360-496-0078
Provider Enumeration Date:
05/03/2007

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: 225100000X , with the licence number:  PT00008727 , 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: 7127327 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0192531 . This is a "LABOR & INDUSTRY PROVIDER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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