1023069747 NPI number — NORTHWEST WEIGHT LOSS SURGERY, PLLC

Table of content: (NPI 1023069747)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023069747 NPI number — NORTHWEST WEIGHT LOSS SURGERY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST WEIGHT LOSS SURGERY, 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:
1023069747
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 130TH ST SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98208-6400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-341-4800
Provider Business Mailing Address Fax Number:
425-385-8476

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 130TH ST SE
Provider Second Line Business Practice Location Address:
FIRST FLOOR
Provider Business Practice Location Address City Name:
EVERETT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98208-6400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-385-2263
Provider Business Practice Location Address Fax Number:
425-385-8476
Provider Enumeration Date:
05/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LUKEVICH
Authorized Official First Name:
GAIA
Authorized Official Middle Name:
E
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
425-385-2263

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  602225209 , 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)

  • Identifier: 602225209 . This is a "STATE LICENSE BUSINESS ID" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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