1730180746 NPI number — CREEKSIDE ORTHOPEDICS, 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 1730180746 NPI number — CREEKSIDE ORTHOPEDICS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CREEKSIDE ORTHOPEDICS, 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:
1730180746
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8051
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YAKIMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98908-0051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-469-1903
Provider Business Mailing Address Fax Number:
509-469-1905

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3907 CREEKSIDE LOOP
Provider Second Line Business Practice Location Address:
STE. 100
Provider Business Practice Location Address City Name:
YAKIMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98902-4879
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-457-1900
Provider Business Practice Location Address Fax Number:
509-853-2700
Provider Enumeration Date:
08/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PLACE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
S
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
509-457-1900

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  MD0012321 , 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: 7126642 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0197897 . This is a "LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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