1376716597 NPI number — STRAIT ORTHOPEDIC SPECIALISTS, PS

Table of content: (NPI 1376716597)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376716597 NPI number — STRAIT ORTHOPEDIC SPECIALISTS, PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STRAIT ORTHOPEDIC SPECIALISTS, PS
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:
MCGOVERN THERAPY SPECIALISTS
Provider Other Organization Name Type Code:
5
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:
1376716597
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1112 CAROLINE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ANGELES
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98362-4204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-417-8630
Provider Business Mailing Address Fax Number:
360-417-8635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
520 N 5TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEQUIM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98382-3079
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-417-8630
Provider Business Practice Location Address Fax Number:
360-417-8635
Provider Enumeration Date:
04/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MCGOVERN
Authorized Official First Name:
REGINA
Authorized Official Middle Name:
MAY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
360-417-8630

Provider Taxonomy Codes

  • Taxonomy code: 207XS0114X , with the licence number:  MD00038097 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , with the licence number: OT00003652 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA10005046 , 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: 147288 . This is a "DEPT. OF LABOR & INDUSTRI" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: CH7730 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7105810 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7682677 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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