1609121854 NPI number — CASCADE CLINIC WALK IN AND PRIMARY CARE LLC

Table of content: (NPI 1609121854)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609121854 NPI number — CASCADE CLINIC WALK IN AND PRIMARY CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CASCADE CLINIC WALK IN AND PRIMARY CARE LLC
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:
CASCADE CLINIC
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:
1609121854
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1420 ROOSEVELT AVE STE 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT VERNON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98273-2687
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-994-0863
Provider Business Mailing Address Fax Number:
360-899-4124

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1420 ROOSEVELT AVE STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98273-2687
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-899-4086
Provider Business Practice Location Address Fax Number:
360-899-4124
Provider Enumeration Date:
07/13/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BRADFORD
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
360-770-4690

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 321303 . This is a "LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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