1033101191 NPI number — CITY OF MONTESANO

Table of content: (NPI 1033101191)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033101191 NPI number — CITY OF MONTESANO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF MONTESANO
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:
1033101191
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
112 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTESANO
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98563-3707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-249-4851
Provider Business Mailing Address Fax Number:
360-249-4971

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 E PIONEER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTESANO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98563-4602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-249-4851
Provider Business Practice Location Address Fax Number:
360-249-4971
Provider Enumeration Date:
08/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WISDOM
Authorized Official First Name:
DEBBIE
Authorized Official Middle Name:
Authorized Official Title or Position:
DEPUTY CLERK
Authorized Official Telephone Number:
360-249-4851

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  14M06 , 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: 9279803 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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