1235683806 NPI number — PAYETTE OF CASCADIA, LLC

Table of content: (NPI 1235683806)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235683806 NPI number — PAYETTE OF CASCADIA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAYETTE OF CASCADIA, 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:
PAYETTE HEALTHCARE OF CASCADIA
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:
1235683806
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
408 S EAGLE RD
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
EAGLE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-416-6633
Provider Business Mailing Address Fax Number:
844-362-3862

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1019 3RD AVENUE SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAYETTE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83661-2832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-678-9474
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/11/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LAFORTE
Authorized Official First Name:
STEVE
Authorized Official Middle Name:
Authorized Official Title or Position:
GENERAL COUNSEL AND DIRECTOR
Authorized Official Telephone Number:
206-351-4535

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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