1326295924 NPI number — ALYSON LEIGH KILGUS DPT

Table of content: ALYSON LEIGH KILGUS DPT (NPI 1326295924)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326295924 NPI number — ALYSON LEIGH KILGUS DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KILGUS
Provider First Name:
ALYSON
Provider Middle Name:
LEIGH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SUCHLAND
Provider Other First Name:
ALYSON
Provider Other Middle Name:
LEIGH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1326295924
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
315 MARTIN L KING JR WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98405-4234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-891-7490
Provider Business Mailing Address Fax Number:
253-863-1052

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21806 103RD AVENUE CT E
Provider Second Line Business Practice Location Address:
#202
Provider Business Practice Location Address City Name:
GRAHAM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98338-8115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-847-3700
Provider Business Practice Location Address Fax Number:
256-847-9622
Provider Enumeration Date:
08/26/2008

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: 225100000X , with the licence number:  PT60028702 , 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: 0291093 . This is a "DEPT. OF LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: P00725348 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8520769 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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