1548370547 NPI number — BROADWAY CLINIC INC

Table of content: (NPI 1548370547)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548370547 NPI number — BROADWAY CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROADWAY CLINIC INC
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:
1548370547
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 149
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ABERDEEN
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98520-0063
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-538-7292
Provider Business Mailing Address Fax Number:
360-533-2566

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 W 4TH ST
Provider Second Line Business Practice Location Address:
SUITE # 105
Provider Business Practice Location Address City Name:
ABERDEEN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98520-3932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-538-7292
Provider Business Practice Location Address Fax Number:
360-533-2566
Provider Enumeration Date:
08/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
ANTOINE
Authorized Official Middle Name:
DOUGLASS
Authorized Official Title or Position:
FAMILY MEDICINE PHYICIAN CEO BROAWA
Authorized Official Telephone Number:
360-538-7292

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7109903 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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