1275789885 NPI number — SANDRA L STORK RC

Table of content: SANDRA L STORK RC (NPI 1275789885)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275789885 NPI number — SANDRA L STORK RC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STORK
Provider First Name:
SANDRA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RC
Provider Gender Code:
F

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:
1275789885
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 157
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEMING
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98244-0157
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-966-2106
Provider Business Mailing Address Fax Number:
360-966-7227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6760 MISSION RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVERSON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98247-9749
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-966-2106
Provider Business Practice Location Address Fax Number:
360-966-7227
Provider Enumeration Date:
08/14/2008

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: 101YP2500X , with the licence number:  RC00013533 , 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: 1981018 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com