1699431627 NPI number — MARK RAUTIOLA

Table of content: MARK RAUTIOLA (NPI 1699431627)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699431627 NPI number — MARK RAUTIOLA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAUTIOLA
Provider First Name:
MARK
Provider Middle Name:
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:
1699431627
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1701
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEWISTON
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83501-1462
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-473-9663
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6975 SW SANDBURG ST STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TIGARD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97223-8089
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-473-9663
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/15/2021

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: 101YM0800X , with the licence number:  C6330 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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