1063417186 NPI number — DR. MARK J BLESSLEY D.C.

Table of content: DR. MARK J BLESSLEY D.C. (NPI 1063417186)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063417186 NPI number — DR. MARK J BLESSLEY D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLESSLEY
Provider First Name:
MARK
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
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:
1063417186
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
204 E 25TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98663-3219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-693-7781
Provider Business Mailing Address Fax Number:
360-693-1688

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
204 E 25TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98663-3219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-693-7781
Provider Business Practice Location Address Fax Number:
360-693-1688
Provider Enumeration Date:
06/15/2005

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: 111N00000X , with the licence number:  OR27136 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X , with the licence number: CH00003457 , 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: 350055943 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8370819 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0154880 . This is a "DEPT. OF LABOR & IND" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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