1275657355 NPI number — JACK M STAGGE P.T., O.C.S.,

Table of content: (NPI 1326363011)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275657355 NPI number — JACK M STAGGE P.T., O.C.S.,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STAGGE
Provider First Name:
JACK
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T., O.C.S.,
Provider Gender Code:
M

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:
1275657355
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
230 GRANT RD
Provider Second Line Business Mailing Address:
STE B27
Provider Business Mailing Address City Name:
EAST WENATCHEE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98802-7715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-884-2992
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
230 GRANT ROAD, SUITE B27
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST WENATCHEE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-884-1437
Provider Business Practice Location Address Fax Number:
509-884-2811
Provider Enumeration Date:
03/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT00005726 , 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: 7052665 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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