1609061969 NPI number — PEACEHEALTH

Table of content: (NPI 1609061969)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609061969 NPI number — PEACEHEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEACEHEALTH
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:
1609061969
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1115 SE 164TH AVE
Provider Second Line Business Mailing Address:
DEPT 358
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98683-9324
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-729-1412
Provider Business Mailing Address Fax Number:
360-501-7555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 NE 87TH AVE
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98664-1965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-514-7374
Provider Business Practice Location Address Fax Number:
360-514-7384
Provider Enumeration Date:
09/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MONTALVO
Authorized Official First Name:
DARRIN
Authorized Official Middle Name:
Authorized Official Title or Position:
EVP CHIEF FINAN-GROWTH OFFICER
Authorized Official Telephone Number:
360-729-1102

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  MD00027022 , 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)





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