1043442759 NPI number — CITY OF CLARKSTON

Table of content: (NPI 1043442759)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043442759 NPI number — CITY OF CLARKSTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF CLARKSTON
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:
1043442759
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3510
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SILVERDALE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98383-3510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-394-7030
Provider Business Mailing Address Fax Number:
360-394-7097

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
820 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARKSTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99403-2634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-758-8681
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/13/2009

Additional Information

Authorized Official

Authorized Official Last Name:
COOPER
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
FIRE CHIEF
Authorized Official Telephone Number:
509-758-8681

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  02M03 , 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: P00811055 . This is a "RAILROAD MEDICARE PTAN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1043442759 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 615253100 . This is a "OWCP-FEDERAL WORKER'S COMP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0259815 . This is a "L&I/CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2006867 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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