1649066218 NPI number — MR. THAD HAOROLD BALLSMIDER SUDPT

Table of content: MR. THAD HAOROLD BALLSMIDER SUDPT (NPI 1649066218)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649066218 NPI number — MR. THAD HAOROLD BALLSMIDER SUDPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALLSMIDER
Provider First Name:
THAD
Provider Middle Name:
HAOROLD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
SUDPT
Provider Gender Code:
M

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:
1649066218
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11459 HAVEKOST RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANACORTES
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98221-8798
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-420-3297
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 E COLLEGE WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98273-5612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-763-5595
Provider Business Practice Location Address Fax Number:
360-399-7639
Provider Enumeration Date:
04/18/2025

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: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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