1245375518 NPI number — FAMILY MEDICAL CENTER OF FORKS, INC, PS

Table of content: (NPI 1245375518)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245375518 NPI number — FAMILY MEDICAL CENTER OF FORKS, INC, PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY MEDICAL CENTER OF FORKS, INC, PS
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:
1245375518
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 455
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORKS
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98331-0455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-374-6224
Provider Business Mailing Address Fax Number:
360-374-6039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
461 G ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORKS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98331-9025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-374-6224
Provider Business Practice Location Address Fax Number:
360-374-6039
Provider Enumeration Date:
02/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KRIEBEL
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
360-374-6224

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  13422 , 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: 7020654 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1770509242 . This is a "LAURA NPI" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7058829 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1659374114 . This is a "DR K NPI #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0048001 . This is a "WA ST L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8156200 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: KR9095 . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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