1700074499 NPI number — LEILANI MOCK LMP

Table of content: LEILANI MOCK LMP (NPI 1700074499)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700074499 NPI number — LEILANI MOCK LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOCK
Provider First Name:
LEILANI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ESTEBAN
Provider Other First Name:
LEILANI
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700074499
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11009
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLYMPIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98508-1009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-352-2037
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1175 CENTER DR
Provider Second Line Business Practice Location Address:
160
Provider Business Practice Location Address City Name:
DUPONT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98327-7733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-964-1559
Provider Business Practice Location Address Fax Number:
253-964-8495
Provider Enumeration Date:
10/09/2007

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: 225700000X , with the licence number:  MA00024496 , 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: 225310 . This is a "L&I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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