1609560242 NPI number — GRETCHEN PAYGE LINES MASTERS INTERN

Table of content: GRETCHEN PAYGE LINES MASTERS INTERN (NPI 1609560242)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609560242 NPI number — GRETCHEN PAYGE LINES MASTERS INTERN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LINES
Provider First Name:
GRETCHEN
Provider Middle Name:
PAYGE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MASTERS INTERN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROWN
Provider Other First Name:
GRETCHEN
Provider Other Middle Name:
PAYGE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609560242
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 S DIVISION ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99202-1510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-879-6454
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2118 E SPRAGUE AVE RM 123
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99202-3125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-838-4651
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/06/2023

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: 101Y00000X , with the licence number:  CG61439998 , 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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