1487077145 NPI number — RESTORATIVE THERAPY SPECIALISTS, PLLC

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 1487077145 NPI number — RESTORATIVE THERAPY SPECIALISTS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RESTORATIVE THERAPY SPECIALISTS, PLLC
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:
1487077145
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1608 S 24TH AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
YAKIMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98902-5719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-388-2270
Provider Business Mailing Address Fax Number:
509-320-4109

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1608 S 24TH AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
YAKIMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98902-5719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-388-2270
Provider Business Practice Location Address Fax Number:
509-320-4109
Provider Enumeration Date:
01/30/2014

Additional Information

Authorized Official

Authorized Official Last Name:
LONGBOTTOM
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
509-388-2270

Provider Taxonomy Codes

  • Taxonomy code: 2251N0400X , with the licence number:  00006243 , 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: 1811251861 . This is a "INDIVIDUAL NPI" identifier . This identifiers is of the category "OTHER".




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