1194820001 NPI number — WASHINGTON STATE DEPARTMENT OF HEALTH

Table of content: (NPI 1194820001)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194820001 NPI number — WASHINGTON STATE DEPARTMENT OF HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WASHINGTON STATE DEPARTMENT OF HEALTH
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:
1194820001
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 47901
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLYMPIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98504-7901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-236-4503
Provider Business Mailing Address Fax Number:
360-236-4500

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1610 NE 150TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHORELINE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98155-7224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-418-5410
Provider Business Practice Location Address Fax Number:
206-418-5415
Provider Enumeration Date:
09/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PEREZ
Authorized Official First Name:
HARVEY
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
ASST SECRETARY, FINANCIAL SERVICES
Authorized Official Telephone Number:
360-236-4503

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9011883 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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