1588795611 NPI number — MRS. MARY SQUIRES RD, CD, CDCES

Table of content: MRS. MARY SQUIRES RD, CD, CDCES (NPI 1588795611)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588795611 NPI number — MRS. MARY SQUIRES RD, CD, CDCES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SQUIRES
Provider First Name:
MARY
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD, CD, CDCES
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STALEY
Provider Other First Name:
MARY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RD, CD, CDE
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1588795611
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3624 NE SITKA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMAS
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98607-7473
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-380-3026
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
203 W 8TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNEWICK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99336-5630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-585-5929
Provider Business Practice Location Address Fax Number:
509-586-5140
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133VN1006X , with the licence number:  DI00001620 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133V00000X , with the licence number: DI00001620 , 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: 8403933 . This is a "DSHS#" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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