1700088002 NPI number — CHILDRENS KIDNEY SPECIALISTS PLLC

Table of content: (NPI 1700088002)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700088002 NPI number — CHILDRENS KIDNEY SPECIALISTS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHILDRENS KIDNEY SPECIALISTS 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:
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:
1700088002
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1935 NW NORFOLK CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97229-8448
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-297-3178
Provider Business Mailing Address Fax Number:
208-381-7495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 E IDAHO ST
Provider Second Line Business Practice Location Address:
200
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83712-6223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-381-7336
Provider Business Practice Location Address Fax Number:
208-381-7495
Provider Enumeration Date:
05/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JENKINS
Authorized Official First Name:
RANDALL
Authorized Official Middle Name:
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
208-381-7336

Provider Taxonomy Codes

  • Taxonomy code: 2080P0210X , with the licence number:  M6943 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000010026970 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 003401500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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