1013307024 NPI number — MR. JUBAL J BEWICK EAMP, MSAOM

Table of content: MR. JUBAL J BEWICK EAMP, MSAOM (NPI 1013307024)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013307024 NPI number — MR. JUBAL J BEWICK EAMP, MSAOM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEWICK
Provider First Name:
JUBAL
Provider Middle Name:
J
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
EAMP, MSAOM
Provider Gender Code:
M

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:
1013307024
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2200 MELROSE ST
Provider Second Line Business Mailing Address:
SUITE 9
Provider Business Mailing Address City Name:
WALLA WALLA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99362-1581
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-876-4597
Provider Business Mailing Address Fax Number:
509-876-4599

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 MELROSE ST
Provider Second Line Business Practice Location Address:
SUITE 9
Provider Business Practice Location Address City Name:
WALLA WALLA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99362-1581
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-876-4597
Provider Business Practice Location Address Fax Number:
509-876-4599
Provider Enumeration Date:
01/28/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  AC60511065 , 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)





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