1174917579 NPI number — GENEVA WOODS HEALTH SUPPLIES PNW, LLC

Table of content: (NPI 1174917579)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174917579 NPI number — GENEVA WOODS HEALTH SUPPLIES PNW, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENEVA WOODS HEALTH SUPPLIES PNW, 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:
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:
1174917579
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 94347
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98124-6647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-588-7241
Provider Business Mailing Address Fax Number:
866-583-9296

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6326 E TRENT AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE VALLEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99212-1220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-867-3466
Provider Business Practice Location Address Fax Number:
866-583-9296
Provider Enumeration Date:
03/24/2015

Additional Information

Authorized Official

Authorized Official Last Name:
AFRASIABI
Authorized Official First Name:
DAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
888-441-1312

Provider Taxonomy Codes

  • Taxonomy code: 332BP3500X , with the licence number:  604-124-465-001-0003 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: 604-124-465-001-0003 , 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: 2092020 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1174917579 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 082809 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1038339970001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1174917579 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500736763 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0226655 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 47576758 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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