1447448279 NPI number — MRS. REBECCA LYNN BOLLING NP

Table of content: PRISCILLA COOK (NPI 1487050555)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447448279 NPI number — MRS. REBECCA LYNN BOLLING NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLLING
Provider First Name:
REBECCA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

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:
1447448279
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
560 CATALINA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASHLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97520-1605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-201-4930
Provider Business Mailing Address Fax Number:
541-201-4931

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2620 E BARNETT RD
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97504-8344
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-789-4281
Provider Business Practice Location Address Fax Number:
541-789-2558
Provider Enumeration Date:
10/05/2007

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: 363LF0000X , with the licence number:  327 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 200850001NP , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 022868 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20850001NP . This is a "OREGON LICENSE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 13995 . This is a "STATE LICENSE" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".
  • Identifier: 327 . This is a "STATE LICENSE" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".




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