1427226968 NPI number — PROGRESS HOUSE, INC

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 1427226968 NPI number — PROGRESS HOUSE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROGRESS HOUSE, INC
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:
1427226968
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1666
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
PLACERVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95667-1666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-626-9240
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5494 PONY EXPRESS TRAIL
Provider Second Line Business Practice Location Address:
HOUSE 1
Provider Business Practice Location Address City Name:
CAMINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-644-3758
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
AVEY
Authorized Official First Name:
TOM
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
530-626-9240

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  090002EN , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0913 . This is a "DRUG MEDI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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