1184311011 NPI number — EMERALD CITY ENHANCED SERVICES

Table of content: (NPI 1184311011)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184311011 NPI number — EMERALD CITY ENHANCED SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMERALD CITY ENHANCED SERVICES
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:
1184311011
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 39460
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEWOOD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98496
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-352-0481
Provider Business Mailing Address Fax Number:
253-212-0360

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11421 PACIFIC HWY SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98499
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-352-0481
Provider Business Practice Location Address Fax Number:
253-212-0360
Provider Enumeration Date:
04/20/2023

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
CLAUDIA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
253-352-0481

Provider Taxonomy Codes

  • Taxonomy code: 3104A0625X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PO2225854 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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