1235671587 NPI number — THIRD EYE IMAGING LLC

Table of content: (NPI 1235671587)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235671587 NPI number — THIRD EYE IMAGING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THIRD EYE IMAGING 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:
THIRD EYE IMAGING
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:
1235671587
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1046
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUNNYSIDE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98944-3046
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-790-0060
Provider Business Mailing Address Fax Number:
866-231-5852

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3405 W NOB HILL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YAKIMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98902-4732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-790-0060
Provider Business Practice Location Address Fax Number:
866-231-5852
Provider Enumeration Date:
11/17/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
EMERY
Authorized Official First Name:
JANNEKE
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
509-833-0494

Provider Taxonomy Codes

  • Taxonomy code: 246XS1301X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 246Z00000X , with the licence number: 131428 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 247100000X , with the licence number: RT00006375 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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