1215471909 NPI number — NORTHWEST MOTHERS MILK BANK

Table of content: (NPI 1215471909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215471909 NPI number — NORTHWEST MOTHERS MILK BANK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST MOTHERS MILK BANK
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:
1215471909
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15875 SW 74TH AVE STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TIGARD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97224-7934
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-469-9555
Provider Business Mailing Address Fax Number:
503-469-0962

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15875 SW 74TH AVE STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TIGARD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97224-7934
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-469-9555
Provider Business Practice Location Address Fax Number:
503-469-0962
Provider Enumeration Date:
12/14/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MONDEAUX
Authorized Official First Name:
LESLEY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
503-332-0436

Provider Taxonomy Codes

  • Taxonomy code: 251V00000X , with the licence number:  542742-96 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BP3500X , with the licence number: 542742-96 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)