1275671927 NPI number — THREE RIVERS LTD.

Table of content: (NPI 1275671927)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275671927 NPI number — THREE RIVERS LTD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THREE RIVERS LTD.
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:
1275671927
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 779
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUNNYSIDE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98944-0779
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-837-5022
Provider Business Mailing Address Fax Number:
509-837-4501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 E EDISON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUNNYSIDE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98944-1620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-837-5022
Provider Business Practice Location Address Fax Number:
509-837-4501
Provider Enumeration Date:
02/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LEMIEUX
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
509-837-5022

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH00001360 , 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: 46630 . This is a "LABOR & INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2070407 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: LE5811 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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