1740369784 NPI number — COUNTY OF MADISON

Table of content: (NPI 1740369784)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740369784 NPI number — COUNTY OF MADISON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTY OF MADISON
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:
6
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:
1740369784
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3510
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SILVERDALE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98383-3510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-585-5242
Provider Business Mailing Address Fax Number:
360-394-7099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
134 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REXBURG
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83440-1922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-359-3010
Provider Business Practice Location Address Fax Number:
208-359-3003
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CHILD
Authorized Official First Name:
COREY
Authorized Official Middle Name:
Authorized Official Title or Position:
FIRE CHIEF
Authorized Official Telephone Number:
208-359-3010

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  7708 , 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: 002943800 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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