1568887404 NPI number — SELKIRK OUTDOOR LEADERSHIP & EDUCATION (SOLE), 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 1568887404 NPI number — SELKIRK OUTDOOR LEADERSHIP & EDUCATION (SOLE), INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SELKIRK OUTDOOR LEADERSHIP & EDUCATION (SOLE), 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:
1568887404
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1255 MEADOWOOD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANDPOINT
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83864-4950
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-946-6960
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 WISCONSIN AVE STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITEFISH
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59937-2304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-351-7653
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/02/2014

Additional Information

Authorized Official

Authorized Official Last Name:
WEBB
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
D
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
208-946-6960

Provider Taxonomy Codes

  • Taxonomy code: 320800000X , with the licence number:  29 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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