1154836872 NPI number — IDEAL OPTION, PLLC

Table of content: (NPI 1154836872)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154836872 NPI number — IDEAL OPTION, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IDEAL OPTION, PLLC
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:
1154836872
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8656 W GAGE BLVD STE 301B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENNEWICK
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99336-7145
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-222-1275
Provider Business Mailing Address Fax Number:
509-491-3031

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1215 120TH AVE NE
Provider Second Line Business Practice Location Address:
201 & 204
Provider Business Practice Location Address City Name:
BELLEVUE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-522-1275
Provider Business Practice Location Address Fax Number:
509-491-3031
Provider Enumeration Date:
12/04/2017

Additional Information

Authorized Official

Authorized Official Last Name:
DAWSON
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
JEFFERSON
Authorized Official Title or Position:
CMO
Authorized Official Telephone Number:
509-222-1275

Provider Taxonomy Codes

  • Taxonomy code: 207QA0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2031254 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com