1225074107 NPI number — RANDALL D COBBLE PAC

Table of content: RANDALL D COBBLE PAC (NPI 1225074107)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225074107 NPI number — RANDALL D COBBLE PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COBBLE
Provider First Name:
RANDALL
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
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:
1225074107
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 TORBETT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99354-2604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-946-7646
Provider Business Mailing Address Fax Number:
509-946-7666

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 GAGE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHLAND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99352-9532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-946-7646
Provider Business Practice Location Address Fax Number:
509-946-7666
Provider Enumeration Date:
06/21/2006

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: 363AM0700X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA10003668 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1005315 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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