1619215183 NPI number — HISTORY MAKERS

Table of content: (NPI 1619215183)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619215183 NPI number — HISTORY MAKERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HISTORY MAKERS
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:
1619215183
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
220 CINBAR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEBURG
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97471-9385
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-229-5263
Provider Business Mailing Address Fax Number:
541-229-5265

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
220 CINBAR DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEBURG
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97471-9385
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-229-5263
Provider Business Practice Location Address Fax Number:
541-229-5265
Provider Enumeration Date:
01/17/2013

Additional Information

Authorized Official

Authorized Official Last Name:
GARDNER
Authorized Official First Name:
MIKE
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
541-229-5263

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X , with the licence number:  15-2204 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 500650323 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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