1669492344 NPI number — JAMES M. WAHL

Table of content: JAMES M. WAHL (NPI 1669492344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669492344 NPI number — JAMES M. WAHL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAHL
Provider First Name:
JAMES
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1669492344
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
320 CENTRAL AVE.
Provider Second Line Business Mailing Address:
SUITE 418
Provider Business Mailing Address City Name:
COOS BAY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97420-9490
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-269-1334
Provider Business Mailing Address Fax Number:
541-269-7824

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 CENTRAL AVE.
Provider Second Line Business Practice Location Address:
SUITE 418
Provider Business Practice Location Address City Name:
COOS BAY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97420-9490
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-269-1334
Provider Business Practice Location Address Fax Number:
541-269-7824
Provider Enumeration Date:
07/19/2006

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: 103T00000X , with the licence number:  0257 , 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: 214288 . This is a "OMAP PROVIDER NUMBER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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