1093462624 NPI number — BENJAMIN JARROD BELLAND CG61278602

Table of content: BENJAMIN JARROD BELLAND CG61278602 (NPI 1093462624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093462624 NPI number — BENJAMIN JARROD BELLAND CG61278602

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BELLAND
Provider First Name:
BENJAMIN
Provider Middle Name:
JARROD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CG61278602
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:
1093462624
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1299
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATTLE GROUND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98604-1299
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-771-0482
Provider Business Mailing Address Fax Number:
360-397-7477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21810 NE 37TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIDGEFIELD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98642-7747
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-771-0482
Provider Business Practice Location Address Fax Number:
360-397-7477
Provider Enumeration Date:
03/03/2022

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: 175T00000X , with the licence number:  CG61278602 , 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)





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