1568135564 NPI number — RACHEL SHADE

Table of content: RACHEL SHADE (NPI 1568135564)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568135564 NPI number — RACHEL SHADE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHADE
Provider First Name:
RACHEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1568135564
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1155
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98586-1155
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-563-0413
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2204 PACIFIC AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98631-3300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-642-3787
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 376K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CM60602536 . This is a "STATE CERTIFICATION" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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