1174609879 NPI number — DR. THAYNE LYNDON BOSH DPT

Table of content: DR. THAYNE LYNDON BOSH DPT (NPI 1174609879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174609879 NPI number — DR. THAYNE LYNDON BOSH DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOSH
Provider First Name:
THAYNE
Provider Middle Name:
LYNDON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPT
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:
1174609879
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3992
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SILVERDALE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98383-3992
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9621 RIDGETOP BLVD NW
Provider Second Line Business Practice Location Address:
SUITE #100
Provider Business Practice Location Address City Name:
SILVERDALE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98383-8502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-337-7662
Provider Business Practice Location Address Fax Number:
360-337-7300
Provider Enumeration Date:
10/27/2006

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: 225100000X , with the licence number:  PT00009351 , 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: 8444077 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9157137 . This is a "CIGNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 91181639719 . This is a "KPS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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