1558364216 NPI number — TOUTLE RIVER RANCH, 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 1558364216 NPI number — TOUTLE RIVER RANCH, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOUTLE RIVER RANCH, 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:
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:
1558364216
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2052
Provider Second Line Business Mailing Address:
907 DOUGLAS STREET
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98632-8179
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-423-6741
Provider Business Mailing Address Fax Number:
360-501-6510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
907 DOUGLAS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98632-2155
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-423-6741
Provider Business Practice Location Address Fax Number:
360-501-6510
Provider Enumeration Date:
05/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MANSKER
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
ELAINE
Authorized Official Title or Position:
DATA COORDINATOR
Authorized Official Telephone Number:
360-423-6741

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  222 , 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: 7119834 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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