1639268469 NPI number — VANCOUVER ENT AND ENT OF THE NORTHWEST PLLC

Table of content: (NPI 1639268469)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639268469 NPI number — VANCOUVER ENT AND ENT OF THE NORTHWEST PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VANCOUVER ENT AND ENT OF THE NORTHWEST PLLC
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:
VANCOUVER EAR, NOSE & THROAT HEAD & NECK SURGERY CENTER
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:
1639268469
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1405 SE 164TH AVE STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98683-9644
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-256-4425
Provider Business Mailing Address Fax Number:
360-260-7249

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14411 NE 20TH AVE STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98686-6432
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-256-4425
Provider Business Practice Location Address Fax Number:
360-260-7249
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KENNEDY
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
360-449-6612

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , 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: 7135502 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 204729 . This is a "WA DEPT OF L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8940474 . This is a "WA CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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