1043740616 NPI number — NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK

Table of content: (NPI 1043740616)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043740616 NPI number — NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST MEDICAL FOUNDATION OF TILLAMOOK
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:
1043740616
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 888860
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90088-8860
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12350 NW MAIN ST STE 112
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BANKS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97106-9045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-842-4444
Provider Business Practice Location Address Fax Number:
503-815-2330
Provider Enumeration Date:
06/15/2017

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
MICAH
Authorized Official Middle Name:
Authorized Official Title or Position:
FO
Authorized Official Telephone Number:
503-815-2263

Provider Taxonomy Codes

  • Taxonomy code: 282NC0060X , with the licence number:  141177 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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