1629175963 NPI number — EAGLE HEALTHCARE, INC

Table of content: (NPI 1629175963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629175963 NPI number — EAGLE HEALTHCARE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAGLE HEALTHCARE, INC
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:
1629175963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12015 115TH AVE NE # E195
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KIRKLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98034-6940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-285-3891
Provider Business Mailing Address Fax Number:
425-285-3899

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 ALDER STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CATHLAMET
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98612-0338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-795-3140
Provider Business Practice Location Address Fax Number:
360-795-3866
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCHMIDT
Authorized Official First Name:
GREG
Authorized Official Middle Name:
Authorized Official Title or Position:
CONTROLLER
Authorized Official Telephone Number:
425-285-3891

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  1332 , 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: 4113320 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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