1417026626 NPI number — BERTHA WHITNEY

Table of content: (NPI 1417026626)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417026626 NPI number — BERTHA WHITNEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BERTHA WHITNEY
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:
1417026626
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9751 N GOVT WAY STE 6
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAYDEN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83835-9645
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-746-8547
Provider Business Mailing Address Fax Number:
208-746-5579

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1927 IDAHO STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-2563
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-746-8547
Provider Business Practice Location Address Fax Number:
208-746-5579
Provider Enumeration Date:
11/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WHITNEY
Authorized Official First Name:
BERTHA
Authorized Official Middle Name:
ELDER
Authorized Official Title or Position:
OWNER CONSULTANT
Authorized Official Telephone Number:
208-746-8547

Provider Taxonomy Codes

  • Taxonomy code: 332S00000X , with the licence number:  H197 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: AU720 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 002656800 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 123516 . This is a "LABOR INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 9040924 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000014644 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: AU738 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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