1477760197 NPI number — PROVAIL

Table of content: (NPI 1477760197)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477760197 NPI number — PROVAIL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVAIL
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:
PROVAIL THERAPEUTIC AND ASSISTIVE TECHNOLOGY CLINIC
Provider Other Organization Name Type Code:
3
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:
1477760197
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12550 AURORA AVE N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98133-8036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-363-7303
Provider Business Mailing Address Fax Number:
206-826-0181

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12550 AURORA AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98133-8036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-363-7303
Provider Business Practice Location Address Fax Number:
206-826-0181
Provider Enumeration Date:
05/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HATZENBELER
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
206-363-7303

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SI00004391 , 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: 55-0174569 . This is a "LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7070949-8347395 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7681083-8464992 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7368087 . This is a "AETNA CLINIC NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7070949-8347429 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7681083-8415291 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 397572001 . This is a "GROUP HEALTH PROVIDER NUM" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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