1740238054 NPI number — SEQUIM PHYSICIAN CLINIC

Table of content: (NPI 1740238054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740238054 NPI number — SEQUIM PHYSICIAN CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SEQUIM PHYSICIAN CLINIC
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:
1740238054
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:
PO BOX 755
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEQUIM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98382-0755
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-683-4181
Provider Business Mailing Address Fax Number:
360-681-3454

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
411 W WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEQUIM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98382-3343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-683-4181
Provider Business Practice Location Address Fax Number:
360-681-3454
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BERRY
Authorized Official First Name:
ALLEN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
360-683-4181

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  MD00018876 , 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: AP30005395 . This is a "LICENSE GLORIA REDMOND" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: AP30003686 . This is a "LICENSE DIANE ROOT-RACINE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7098833 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: MD00018876 . This is a "LICENSE ALLEN BERRY" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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