1396130779 NPI number — JUDITH K CAPORICCIO

Table of content: (NPI 1396130779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396130779 NPI number — JUDITH K CAPORICCIO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JUDITH K CAPORICCIO
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:
1396130779
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
579 S 40TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST RICHLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99353-5080
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-736-6311
Provider Business Mailing Address Fax Number:
509-736-6336

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 COLUMBIA PARK TRL
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
RICHLAND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99352-4772
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-736-6311
Provider Business Practice Location Address Fax Number:
509-736-6336
Provider Enumeration Date:
04/01/2015

Additional Information

Authorized Official

Authorized Official Last Name:
CAPORICCIO
Authorized Official First Name:
JUDITH
Authorized Official Middle Name:
Authorized Official Title or Position:
SUPERVISING PROVIDER
Authorized Official Telephone Number:
509-736-6311

Provider Taxonomy Codes

  • Taxonomy code: 175F00000X , with the licence number:  NT 60057466 , 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)





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