1720004112 NPI number — CITY OF WALLA WALLA

Table of content: (NPI 1720004112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720004112 NPI number — CITY OF WALLA WALLA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF WALLA WALLA
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:
1720004112
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
170 N WILBUR AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALLA WALLA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99362-2548
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-529-4083
Provider Business Mailing Address Fax Number:
509-529-0694

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
170 N WILBUR AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLA WALLA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99362-2548
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-529-4083
Provider Business Practice Location Address Fax Number:
509-529-0694
Provider Enumeration Date:
07/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MORRIS
Authorized Official First Name:
BRAD
Authorized Official Middle Name:
W
Authorized Official Title or Position:
DEPUTY CHIEF OF EMS
Authorized Official Telephone Number:
509-529-4083

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  36M04 , 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: 590161247 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 029454 . This is a "OREGON MEDICAID" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 193657900 . This is a "OFFICE WORKERS COMP" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 9150509 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 12755 . This is a "WASHINGTON L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8901205 . This is a "CRIME VICTIM PROVIDER NUM" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: ITA9023839 . This is a "INVOLUNTARY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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