1316032451 NPI number — LONGVIEW FOOT & ANKLE CLINIC

Table of content: (NPI 1316032451)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316032451 NPI number — LONGVIEW FOOT & ANKLE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LONGVIEW FOOT & ANKLE CLINIC
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:
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:
1316032451
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
725 NW 19TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97209-1301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-243-2699
Provider Business Mailing Address Fax Number:
503-243-2698

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
783 COMMERCE AVE
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-575-9161
Provider Business Practice Location Address Fax Number:
360-575-9306
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCCLANAHAN
Authorized Official First Name:
RAY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
360-575-9161

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  DP00317 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , with the licence number: PO00000596 , 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: 129510 . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: MC5942 . This is a "REGENCE RIDER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1101682 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8397218 . This is a "DMERC DSHS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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