1467480939 NPI number — ROHN DALE WALLACE SUBMARINE IDC

Table of content: ROHN DALE WALLACE SUBMARINE IDC (NPI 1467480939)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467480939 NPI number — ROHN DALE WALLACE SUBMARINE IDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
ROHN
Provider Middle Name:
DALE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SUBMARINE IDC
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:
1467480939
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4417 WATERMAN RIDGE LN E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ORCHARD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98366-8001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
USS OHIO SSGN 726 GOLD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SILVERDALE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-476-8351
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/30/2006

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: 1710I1002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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