1285695007 NPI number — DALE E ANDERSON LCPO

Table of content: DALE E ANDERSON LCPO (NPI 1285695007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285695007 NPI number — DALE E ANDERSON LCPO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
DALE
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPO
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:
1285695007
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1994
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLYMPIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98507-1994
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-956-3333
Provider Business Mailing Address Fax Number:
360-956-3339

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2102 CARRIAGE DR SW
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98502-5700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-956-3333
Provider Business Practice Location Address Fax Number:
360-956-3339
Provider Enumeration Date:
03/31/2006

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: 222Z00000X , with the licence number:  OI00000176 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 224P00000X , with the licence number: PS00000283 , 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: 3580WE . This is a "BLUESHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 9051483 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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