1083831556 NPI number — EASTPORT PSR, L.L.P.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083831556 NPI number — EASTPORT PSR, L.L.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTPORT PSR, L.L.P.
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:
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:
1083831556
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1093
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BONNERS FERRY
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83805-1093
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-946-3604
Provider Business Mailing Address Fax Number:
208-267-1681

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7222 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BONNERS FERRY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-946-3604
Provider Business Practice Location Address Fax Number:
208-267-1681
Provider Enumeration Date:
04/19/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
ANNA
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
PSYCHOSOCIAL REHABILITATION SPECIAL
Authorized Official Telephone Number:
12082677290

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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