1073674040 NPI number — ENUMCLAW REGIONAL HOSPITAL ASSOCIATION

Table of content: (NPI 1073674040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073674040 NPI number — ENUMCLAW REGIONAL HOSPITAL ASSOCIATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ENUMCLAW REGIONAL HOSPITAL ASSOCIATION
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:
1073674040
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 31001-1482
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91110-1482
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-802-3265
Provider Business Mailing Address Fax Number:
360-825-9046

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1455 BATTERSBY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENUMCLAW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98022-3634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-802-3265
Provider Business Practice Location Address Fax Number:
360-825-9046
Provider Enumeration Date:
12/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FITZGERALD
Authorized Official First Name:
MIKE
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
253-680-4005

Provider Taxonomy Codes

  • Taxonomy code: 282NC0060X , with the licence number:  H035 , 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: 3310406 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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