1316027048 NPI number — DR. KENNETH J CORLISS OD

Table of content: DR. KENNETH J CORLISS OD (NPI 1316027048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316027048 NPI number — DR. KENNETH J CORLISS OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORLISS
Provider First Name:
KENNETH
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
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:
1316027048
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1266
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUYALLUP
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98371-0237
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-845-0585
Provider Business Mailing Address Fax Number:
253-845-1939

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
312 4TH ST SE
Provider Second Line Business Practice Location Address:
UNIT A
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98372-3269
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-845-0585
Provider Business Practice Location Address Fax Number:
253-845-1939
Provider Enumeration Date:
10/17/2006

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: 152W00000X , with the licence number:  OD915 , 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: 2211704 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0016684 . This is a "L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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