1548666175 NPI number — THE FIDELIS GROUP INC

Table of content: (NPI 1548666175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548666175 NPI number — THE FIDELIS GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE FIDELIS GROUP 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:
6
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:
1548666175
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
921 LAKERIDGE WAY SW STE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLYMPIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98502-6081
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-489-1621
Provider Business Mailing Address Fax Number:
360-339-4476

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
921 LAKERIDGE WAY SW STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98502-6081
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-489-1621
Provider Business Practice Location Address Fax Number:
360-339-4476
Provider Enumeration Date:
11/10/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LANE
Authorized Official First Name:
SARAH
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
360-481-8147

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X , with the licence number:  603-431-168 , 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)