1841475803 NPI number — NORTHWEST COSMETIC SURGERY, LLC

Table of content: (NPI 1841475803)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841475803 NPI number — NORTHWEST COSMETIC SURGERY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST COSMETIC SURGERY, LLC
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:
1841475803
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
777 SW MILL VIEW WAY STE 250
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97702-1140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-728-3184
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
777 SW MILL VIEW WAY
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
BEND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97702-1140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-388-1022
Provider Business Practice Location Address Fax Number:
541-322-7002
Provider Enumeration Date:
01/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GALLAGHER
Authorized Official First Name:
GARY
Authorized Official Middle Name:
LYLE
Authorized Official Title or Position:
MANAGER/MEMBER
Authorized Official Telephone Number:
417-283-1845

Provider Taxonomy Codes

  • Taxonomy code: 208200000X , with the licence number:  MD21961 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com