1457461410 NPI number — ALLERGY & ASTHMA SPECIALTY SERVICE PS

Table of content: (NPI 1457461410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457461410 NPI number — ALLERGY & ASTHMA SPECIALTY SERVICE PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALLERGY & ASTHMA SPECIALTY SERVICE PS
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:
1457461410
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11307 BRIDGEPORT WAY SW
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
LAKEWOOD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98499-3024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-589-1380
Provider Business Mailing Address Fax Number:
253-589-1786

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11307 BRIDGEPORT WAY SW
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98499-3024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-589-1380
Provider Business Practice Location Address Fax Number:
253-589-1786
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ANDRADE
Authorized Official First Name:
W
Authorized Official Middle Name:
PIERRE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
253-588-4878

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7041486 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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