1598349631 NPI number — VANGUARD PSYCHIATRY LLC

Table of content: (NPI 1598349631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598349631 NPI number — VANGUARD PSYCHIATRY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VANGUARD PSYCHIATRY 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:
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:
1598349631
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4935 STATE ROUTE 20
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT TOWNSEND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98368-9701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-753-1193
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
221 W PATISON ST STE 203A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT HADLOCK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98339-9751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-509-7764
Provider Business Practice Location Address Fax Number:
360-369-6722
Provider Enumeration Date:
05/05/2021

Additional Information

Authorized Official

Authorized Official Last Name:
DEFILIPPO
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
MATTHEW
Authorized Official Title or Position:
OWNER/CEO
Authorized Official Telephone Number:
650-753-1193

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2041287 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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