1164491403 NPI number — TOMMY L LOVE DO

Table of content: TOMMY L LOVE DO (NPI 1164491403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164491403 NPI number — TOMMY L LOVE DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOVE
Provider First Name:
TOMMY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1164491403
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11400 SE 8TH ST
Provider Second Line Business Mailing Address:
STE 210
Provider Business Mailing Address City Name:
BELLEVUE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98004-6461
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-688-3730
Provider Business Mailing Address Fax Number:
425-453-6345

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1740 NW MAPLE ST
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
ISSAQUAH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98027-8924
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-313-4800
Provider Business Practice Location Address Fax Number:
425-391-1689
Provider Enumeration Date:
03/17/2006

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: 207PE0005X , with the licence number:  4551473-1204 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: D3487 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1164491403 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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