1720021330 NPI number — CRAIG ROUSE

Table of content: CRAIG ROUSE (NPI 1720021330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720021330 NPI number — CRAIG ROUSE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROUSE
Provider First Name:
CRAIG
Provider Middle Name:
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:
1720021330
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9321 MILBURN LOOP SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LACEY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98513-3420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-790-1669
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8160 FREEDOM LN NE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
LACEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98516-4753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-455-4425
Provider Business Practice Location Address Fax Number:
360-455-3200
Provider Enumeration Date:
06/13/2006

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: 152W00000X , with the licence number:  OD00003743 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 226 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: MR0424806 , 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: 202160317 . This is a "TRICARE PIN #" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".
  • Identifier: 4536RO . This is a "REGENCE BLUE SHIELD PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 721551995 . This is a "TRICARE PIN #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 410048942 . This is a "RAILROAD MEDICARE PIN #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7283193 . This is a "AETNA PPO PROVIDER #" identifier . This identifiers is of the category "OTHER".
  • Identifier: OD2260 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00327511 . This is a "MEDICARE RAILROAD CARRIER GROUP # DE9528" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 3183314 . This is a "AETNA HMO PROVIDER #" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com