1205163524 NPI number — PECKHAM ENTERPRISES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205163524 NPI number — PECKHAM ENTERPRISES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PECKHAM ENTERPRISES, 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:
1205163524
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3007 6TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98406-6202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-761-7795
Provider Business Mailing Address Fax Number:
253-761-7796

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3007 6TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98406-6202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-761-7795
Provider Business Practice Location Address Fax Number:
253-761-7796
Provider Enumeration Date:
11/06/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MOESER-PECKHAM
Authorized Official First Name:
KATHRYN
Authorized Official Middle Name:
CARTER
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
253-761-7795

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  8647 , 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: 8373581 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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