1366499824 NPI number — HAGGEN OPCO NORTH LLC

Table of content: (NPI 1366499824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366499824 NPI number — HAGGEN OPCO NORTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HAGGEN OPCO NORTH 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:
Provider Other Organization Name Type Code:
6
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:
1366499824
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2211 RIMLAND DR
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
BELLINGHAM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98226-5664
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-733-8720
Provider Business Mailing Address Fax Number:
360-752-6437

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14300 SW BARROW RD
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:
97223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-590-4697
Provider Business Practice Location Address Fax Number:
503-590-3804
Provider Enumeration Date:
05/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DIPASQUA
Authorized Official First Name:
GAETANO
Authorized Official Middle Name:
Authorized Official Title or Position:
CORPORATE SENIOR VICE PRESIDENT, PH
Authorized Official Telephone Number:
360-650-8204

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  0001617 , 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)

  • Identifier: 2151119 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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