1598717860 NPI number — JOHN RANDALL SAMPLES

Table of content: JOHN RANDALL SAMPLES (NPI 1598717860)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598717860 NPI number — JOHN RANDALL SAMPLES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SAMPLES
Provider First Name:
JOHN
Provider Middle Name:
RANDALL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1598717860
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 LILLY RD NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLYMPIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98506-5030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-456-4800
Provider Business Mailing Address Fax Number:
360-456-4812

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 LILLY RD NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98506-5030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-456-4800
Provider Business Practice Location Address Fax Number:
360-456-4800
Provider Enumeration Date:
05/16/2006

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: 207W00000X , with the licence number:  MD 13791 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: MD00030114 , 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: 289959 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 360398 . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2044175 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 180040576 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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