1568699197 NPI number — LSREF GOLDEN OPS 26 (WA), LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568699197 NPI number — LSREF GOLDEN OPS 26 (WA), LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LSREF GOLDEN OPS 26 (WA), LLC
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:
1568699197
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 STEVENS AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
SOLANA BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92075-2055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 S KITSAP BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ORCHARD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98366-3778
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-874-7400
Provider Business Practice Location Address Fax Number:
360-874-1969
Provider Enumeration Date:
06/22/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PETERSON
Authorized Official First Name:
WICK
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE VICE PRESIDENT
Authorized Official Telephone Number:
858-775-5857

Provider Taxonomy Codes

  • Taxonomy code: 311500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 315196 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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