1588774780 NPI number — LOIS THETFORD AP-C

Table of content: LOIS THETFORD AP-C (NPI 1588774780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588774780 NPI number — LOIS THETFORD AP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THETFORD
Provider First Name:
LOIS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AP-C
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:
1588774780
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
905 SPRUCE ST
Provider Second Line Business Mailing Address:
STE. 300
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98104-2474
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-461-6935
Provider Business Mailing Address Fax Number:
206-461-8382

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1629 N 45TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98103-6701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-633-3350
Provider Business Practice Location Address Fax Number:
206-633-3113
Provider Enumeration Date:
08/30/2006

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: 363A00000X , with the licence number:  PA10000739 , 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: 8140543 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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