1548489602 NPI number — NORTH PACIFIC DERMATOLOGY A MEDICAL CORPORATION

Table of content: (NPI 1548489602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548489602 NPI number — NORTH PACIFIC DERMATOLOGY A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH PACIFIC DERMATOLOGY A MEDICAL CORPORATION
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:
1548489602
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1575 S RAILROAD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRESCENT CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95531-6821
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-464-8335
Provider Business Mailing Address Fax Number:
707-464-8339

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4715 VALLEY WEST BLVD
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
ARCATA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95521-3586
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-822-3376
Provider Business Practice Location Address Fax Number:
707-822-5053
Provider Enumeration Date:
04/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KINSLEY
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
707-822-3376

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  G77600 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: G77600 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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