1417419268 NPI number — ALLIES & MENTORS LLC

Table of content: (NPI 1417419268)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417419268 NPI number — ALLIES & MENTORS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALLIES & MENTORS LLC
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:
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:
1417419268
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5820 NW VILLAGE GREEN PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORVALLIS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97330-9834
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-829-1747
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
408 SW MONROE AVE # L-191
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORVALLIS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97333-7210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-829-1747
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/02/2019

Additional Information

Authorized Official

Authorized Official Last Name:
BIGRAS
Authorized Official First Name:
SHELIA
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
541-829-1747

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DZ1341 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com