1205592516 NPI number — HEATHER FUDGE LLC

Table of content: (NPI 1205592516)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205592516 NPI number — HEATHER FUDGE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEATHER FUDGE LLC
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:
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:
1205592516
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUGENE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97440-3303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-870-3394
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
438 CHARNELTON ST STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97401-2760
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-870-3394
Provider Business Practice Location Address Fax Number:
541-543-2525
Provider Enumeration Date:
11/10/2021

Additional Information

Authorized Official

Authorized Official Last Name:
FUDGE
Authorized Official First Name:
HEATHER
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER, PROVIDER
Authorized Official Telephone Number:
360-870-3944

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 500660658 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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