1679633192 NPI number — BLC - PARK PLACE, LLC

Table of content: (NPI 1679633192)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679633192 NPI number — BLC - PARK PLACE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLC - PARK PLACE, 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:
PARK PLACE
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:
1679633192
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 S PARK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPOKANE VALLEY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99212-0593
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-922-7224
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 N WABASH AVE
Provider Second Line Business Practice Location Address:
SUITE 1400
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60611-3586
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
312-977-3700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCHULTE
Authorized Official First Name:
MARK
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
312-977-3700

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  BH 1759 , 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: 652398 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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