1699970814 NPI number — AGING WISDOM INC

Table of content: (NPI 1699970814)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699970814 NPI number — AGING WISDOM INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AGING WISDOM 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:
LISA MAYFIELD
Provider Other Organization Name Type Code:
3
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:
1699970814
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 31175
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98103-1175
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-660-3276
Provider Business Mailing Address Fax Number:
866-464-8906

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 DEXTER AVE N STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98109-4342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-660-3276
Provider Business Practice Location Address Fax Number:
866-464-8906
Provider Enumeration Date:
06/18/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MAYFIELD
Authorized Official First Name:
LISA
Authorized Official Middle Name:
DEROSIER
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
206-660-3276

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  LH00007998 , 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)