1417143728 NPI number — NICO ROUSE CORPORATION

Table of content: (NPI 1417143728)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417143728 NPI number — NICO ROUSE CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NICO ROUSE CORPORATION
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:
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:
1417143728
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9321 MILBURN LOOP SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LACEY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98513-3420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-790-1669
Provider Business Mailing Address Fax Number:
360-456-1545

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2202 LIGGETT AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT LEWIS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98433-9500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-964-4140
Provider Business Practice Location Address Fax Number:
253-964-1696
Provider Enumeration Date:
09/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROUSE
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
FORREST
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
360-790-1669

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OD00003743 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: OD00004138 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: OD00003984 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 4536RO . This is a "REGENCE BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3183314 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7283193 . This is a "AETNA PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00327511 DE9528 . This is a "MEDICARE RAIL ROAD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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