1194276550 NPI number — MR. DYLAN E SCHMICK MAL, LAT, ATC

Table of content: MR. DYLAN E SCHMICK MAL, LAT, ATC (NPI 1194276550)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194276550 NPI number — MR. DYLAN E SCHMICK MAL, LAT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCHMICK
Provider First Name:
DYLAN
Provider Middle Name:
E
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MAL, LAT, ATC
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:
1194276550
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 75
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENDICOTT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-953-1398
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1910 UNIVERSITY DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-953-1398
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/20/2016

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: 2255A2300X , with the licence number:  AT-546 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: AT-546 . This is a "IDAHO STATE BOARD OF MEDICINE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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