1154503605 NPI number — CHARLES A WARDLE

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 1154503605 NPI number — CHARLES A WARDLE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARLES A WARDLE
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:
1154503605
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 928
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98632-7582
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-423-7650
Provider Business Mailing Address Fax Number:
360-423-2346

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1426 COMMERCE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98632-3720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-423-7650
Provider Business Practice Location Address Fax Number:
360-423-2346
Provider Enumeration Date:
11/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
DARCY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
360-423-7650

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  907 , 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: DG6451 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2046902 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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