1417002064 NPI number — CRYSTAL L DAVIS LMP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417002064 NPI number — CRYSTAL L DAVIS LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS
Provider First Name:
CRYSTAL
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOTTELL
Provider Other First Name:
CRYSTAL
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1417002064
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
224 PAINE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CASTLE ROCK
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98611-8708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-274-2353
Provider Business Mailing Address Fax Number:
360-274-2354

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
139 1ST AVE. SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASTLE ROCK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-274-2353
Provider Business Practice Location Address Fax Number:
360-274-2354
Provider Enumeration Date:
01/24/2007

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: 225700000X , with the licence number:  MA00019024 , 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: 1055113 . This is a "AMERICAN SPECIALTY HEALTH" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 3804HO . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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