1134472947 NPI number — EPPEL FAMILY MEDICINE LLC

Table of content: (NPI 1134472947)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134472947 NPI number — EPPEL FAMILY MEDICINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EPPEL FAMILY MEDICINE LLC
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:
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:
1134472947
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1950 POTTERY AVE
Provider Second Line Business Mailing Address:
STE 140
Provider Business Mailing Address City Name:
PORT ORCHARD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98366-2592
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-876-5440
Provider Business Mailing Address Fax Number:
360-876-0718

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1950 POTTERY AVE
Provider Second Line Business Practice Location Address:
STE 140
Provider Business Practice Location Address City Name:
PORT ORCHARD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98366-2592
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-876-5440
Provider Business Practice Location Address Fax Number:
360-876-0718
Provider Enumeration Date:
10/17/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
POND
Authorized Official First Name:
WENDIE
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
360-479-0508

Provider Taxonomy Codes

  • Taxonomy code: 207QG0300X , with the licence number:  1977 , 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)