1497272488 NPI number — MR. WALTER EUGENE MOYER CO60676277

Table of content: MR. WALTER EUGENE MOYER CO60676277 (NPI 1497272488)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497272488 NPI number — MR. WALTER EUGENE MOYER CO60676277

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOYER
Provider First Name:
WALTER
Provider Middle Name:
EUGENE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CO60676277
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:
1497272488
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
921 14TH AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98632
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-423-0203
Provider Business Mailing Address Fax Number:
360-577-0269

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 SIMPSON AVENUE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
ABERDEEN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-612-0012
Provider Business Practice Location Address Fax Number:
360-218-5945
Provider Enumeration Date:
08/29/2017

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: 101YA0400X , with the licence number:  CO60676277 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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