1194864868 NPI number — BRAUTIGAM & SCHNIBBE O DS P S

Table of content: (NPI 1194864868)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194864868 NPI number — BRAUTIGAM & SCHNIBBE O DS P S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRAUTIGAM & SCHNIBBE O DS P S
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:
BROADWAY EYECARE CENTER
Provider Other Organization Name Type Code:
3
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:
1194864868
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12121 E BROADWAY AVE STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPOKANE VALLEY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99206-4972
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-928-1212
Provider Business Mailing Address Fax Number:
509-924-5035

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12121 E BROADWAY AVE STE 1
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:
99206-4972
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-928-1212
Provider Business Practice Location Address Fax Number:
509-924-5035
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BRAUTIGAM
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
OWNER OPTOMETRIST
Authorized Official Telephone Number:
509-928-1212

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OD00000930 , 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: DG8772 . This is a "RAILROAD GROUP" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1003882226 . This is a "NPI - DALE SCHNIBBE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1467428458 . This is a "NPI- RICHARD G. BRAUTIGAM" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 410006929 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: DG8772 . This is a "PTAN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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