1508115940 NPI number — MICHELLE DRAGOO LMP

Table of content: (NPI 1508115940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508115940 NPI number — MICHELLE DRAGOO LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHELLE DRAGOO LMP
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:
1508115940
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 214
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIDGEFIELD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98642-0214
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-721-5195
Provider Business Mailing Address Fax Number:
360-887-2984

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
414 PIONEER ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
RIDGEFIELD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98642-4512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-721-5195
Provider Business Practice Location Address Fax Number:
360-887-2984
Provider Enumeration Date:
08/30/2012

Additional Information

Authorized Official

Authorized Official Last Name:
DRAGOO
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
360-721-5195

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  MA00014675 , 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)

  • Identifier: 0190344 . This is a "WASHINGTON LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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