1417088824 NPI number — EDWIN CHARLES GIBBS DC ND LAC

Table of content: MR. MICHAEL BADILLO (NPI 1417190687)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417088824 NPI number — EDWIN CHARLES GIBBS DC ND LAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBBS
Provider First Name:
EDWIN
Provider Middle Name:
CHARLES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DC ND LAC
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:
1417088824
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
45 N HOLLADAY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEASIDE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-738-7343
Provider Business Mailing Address Fax Number:
503-738-9946

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
45 N HOLLADAY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEASIDE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-738-7343
Provider Business Practice Location Address Fax Number:
503-738-9946
Provider Enumeration Date:
03/08/2007

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: 111N00000X , with the licence number:  272219 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 171100000X , with the licence number: AC00733 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 175F00000X , with the licence number: 1078 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 862925004 . This is a "REGENCE BLUE CROSS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 213146 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 076724 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 862925003 . This is a "REGENCE BLUE CROSS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 862925001 . This is a "REGENCE BLUE CROSS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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