1295855013 NPI number — PUGET SOUND KIDNEY CENTERS

Table of content: (NPI 1295855013)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295855013 NPI number — PUGET SOUND KIDNEY CENTERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PUGET SOUND KIDNEY CENTERS
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:
PSKC - WHIDBEY ISLAND
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:
1295855013
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1005 PACIFIC AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98201-4148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-259-5195
Provider Business Mailing Address Fax Number:
425-259-4890

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
430 SE MIDWAY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK HARBOR
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98277-5017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-679-6706
Provider Business Practice Location Address Fax Number:
360-679-6957
Provider Enumeration Date:
03/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KELLY
Authorized Official First Name:
HAROLD
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT & CEO
Authorized Official Telephone Number:
425-259-5195

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , 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: 3144805 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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