1174890867 NPI number — JILL BOOSHU CHA IV

Table of content: JILL BOOSHU CHA IV (NPI 1174890867)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174890867 NPI number — JILL BOOSHU CHA IV

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOOSHU
Provider First Name:
JILL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CHA IV
Provider Gender Code:
F

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:
1174890867
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
190 CLINIC ROAD
Provider Second Line Business Mailing Address:
BOX 190
Provider Business Mailing Address City Name:
GAMBELL
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99742-0190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-985-5015
Provider Business Mailing Address Fax Number:
907-985-5085

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
190 CLINIC ROAD
Provider Second Line Business Practice Location Address:
BOX 190
Provider Business Practice Location Address City Name:
GAMBELL
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99742-0190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-985-5015
Provider Business Practice Location Address Fax Number:
907-985-5085
Provider Enumeration Date:
11/23/2011

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: 172V00000X , with the licence number:  03-602-IV , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CHA-IV . This is a "03-602-IV" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".




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