1386929883 NPI number — MR. CHAKA J. BLOODSAW I LMT #16671

Table of content: MR. CHAKA J. BLOODSAW I LMT #16671 (NPI 1386929883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386929883 NPI number — MR. CHAKA J. BLOODSAW I LMT #16671

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLOODSAW
Provider First Name:
CHAKA
Provider Middle Name:
J.
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
I
Provider Credential Text:
LMT #16671
Provider Gender Code:
M

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:
1386929883
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 351
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEHALEM
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97131-0351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-368-7964
Provider Business Mailing Address Fax Number:
503-368-7964

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36450 N. FORK RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEHALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-368-7964
Provider Business Practice Location Address Fax Number:
503-368-7964
Provider Enumeration Date:
10/15/2011

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: 172M00000X , with the licence number:  16671 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 172M00000X , with the licence number: 60134001 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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