1821101197 NPI number — OLYMPIA MULTI-SPECIALTY CLINIC AMBULATORY PROCEDURES CNTR PLLC

Table of content: AREONA NECOLE BENNETT BT (NPI 1083387054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821101197 NPI number — OLYMPIA MULTI-SPECIALTY CLINIC AMBULATORY PROCEDURES CNTR PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OLYMPIA MULTI-SPECIALTY CLINIC AMBULATORY PROCEDURES CNTR 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:
1821101197
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
406 BLACK HILLS LN SW STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLYMPIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98502-8144
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-704-3401
Provider Business Mailing Address Fax Number:
360-754-1783

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3920 CAPITOL MALL DR SW
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98502-8700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-704-3401
Provider Business Practice Location Address Fax Number:
360-754-0298
Provider Enumeration Date:
08/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCCABE
Authorized Official First Name:
MARSHALL
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
360-704-3401

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  FX00057092 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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