1881912145 NPI number — NOOKSACK CENTRAL MANAGEMENT SYSTEM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881912145 NPI number — NOOKSACK CENTRAL MANAGEMENT SYSTEM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NOOKSACK CENTRAL MANAGEMENT SYSTEM
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:
1881912145
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 157
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEMING
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98244-0157
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-966-7704
Provider Business Mailing Address Fax Number:
360-966-4225

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3003 CABIN CREEK ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EASTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-508-3967
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/12/2010

Additional Information

Authorized Official

Authorized Official Last Name:
COLLINS
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF TREATMENT SERVICES
Authorized Official Telephone Number:
360-966-7704

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1980911 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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