1669663936 NPI number — VANCUVER ENT AND ENT OPF NW, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669663936 NPI number — VANCUVER ENT AND ENT OPF NW, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VANCUVER ENT AND ENT OPF NW, PLLC
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:
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:
1669663936
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1801 1ST AVE
Provider Second Line Business Mailing Address:
SUITE 3A
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98632-3270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-636-4469
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 1ST AVE
Provider Second Line Business Practice Location Address:
SUITE 3A
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98632-3270
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-636-4469
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
EBY
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
360-636-4469

Provider Taxonomy Codes

  • Taxonomy code: 332S00000X , with the licence number:  LD00001333 , 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: 9059015 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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