1174732556 NPI number — KITSAP EYE PHYSICIANS PS

Table of content: (NPI 1174732556)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174732556 NPI number — KITSAP EYE PHYSICIANS PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KITSAP EYE PHYSICIANS PS
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:
1174732556
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2655 WHEATON WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BREMERTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98310-3318
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-377-3703
Provider Business Mailing Address Fax Number:
360-377-9469

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1740 POTTERY AVENUE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
PORT ORCHARD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98366
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-895-0847
Provider Business Practice Location Address Fax Number:
360-876-5771
Provider Enumeration Date:
05/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HOLDREN
Authorized Official First Name:
DALE
Authorized Official Middle Name:
N
Authorized Official Title or Position:
OWNER PRESIDENT
Authorized Official Telephone Number:
360-377-3703

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7071863 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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