1376646380 NPI number — COUNTY OF LAKE

Table of content: (NPI 1376646380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376646380 NPI number — COUNTY OF LAKE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTY OF LAKE
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:
1376646380
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:
100 N D ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
LAKEVIEW
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97630-1540
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-947-6045
Provider Business Mailing Address Fax Number:
541-947-4563

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 N D ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LAKEVIEW
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97630-1540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-947-6045
Provider Business Practice Location Address Fax Number:
541-947-4563
Provider Enumeration Date:
09/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILKIE
Authorized Official First Name:
MARY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
541-947-6045

Provider Taxonomy Codes

  • Taxonomy code: 163WC1500X , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X , with the licence number: 93-60023202 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QA0005X , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP0905X , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01358700 . This is a "BLUE CROSS PROVIDER NUMBE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 320989 . This is a "OMAP FAMILY PLANNING PIN" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 097360 . This is a "OMAP PIN" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 320989 . This is a "OMAP PROVIDERS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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