1578920799 NPI number — SOLE INNOVATIONS

Table of content: MR. BENJAMIN WATSON PA-C (NPI 1013466200)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578920799 NPI number — SOLE INNOVATIONS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOLE INNOVATIONS
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:
REBOUND MEDICAL SOLUTIONS
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:
1578920799
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 HOT SPRINGS RD
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
CARSON CITY
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89706-1647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-849-0244
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10051 LAKE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRUCKEE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96161-0445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-587-7461
Provider Business Practice Location Address Fax Number:
530-587-1149
Provider Enumeration Date:
01/19/2016

Additional Information

Authorized Official

Authorized Official Last Name:
KULIFAJ
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
775-750-6772

Provider Taxonomy Codes

  • Taxonomy code: 222Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: C52332 . This is a "BOC" identifier . This identifiers is of the category "OTHER".




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