1164695482 NPI number — JS STAFFORD ENTERPRISES, INC.

Table of content: (NPI 1164695482)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164695482 NPI number — JS STAFFORD ENTERPRISES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JS STAFFORD ENTERPRISES, INC.
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:
1164695482
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34952 S ELLIS RD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
MOLALLA
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97038-8478
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-829-5918
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
34952 S ELLIS RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MOLALLA
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97038-8478
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-829-5918
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
STAFFORD
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
503-829-5918

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  10643 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5980280001 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 612889300 . This is a "DOL FECA #" identifier . This identifiers is of the category "OTHER".




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