1336102318 NPI number — DM MANAGEMENT PC

Table of content: (NPI 1336102318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336102318 NPI number — DM MANAGEMENT PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DM MANAGEMENT PC
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:
6
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:
1336102318
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2321 E GALA ST
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-4881
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-888-4321
Provider Business Mailing Address Fax Number:
208-895-8747

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2321 E GALA ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83642-4881
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-888-4321
Provider Business Practice Location Address Fax Number:
208-895-8747
Provider Enumeration Date:
04/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WALKER
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
OWNER/THERAPIST
Authorized Official Telephone Number:
208-888-4321

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: TA922 . This is a "BLUE CROSS OF IDAHO GROUP" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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