1730233800 NPI number — SEDRO WOOLLEY FAMILY MEDICINE PLLC

Table of content: (NPI 1730233800)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730233800 NPI number — SEDRO WOOLLEY FAMILY MEDICINE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SEDRO WOOLLEY FAMILY MEDICINE 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:
1730233800
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 450
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEDRO WOOLLEY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98284-0450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-855-1411
Provider Business Mailing Address Fax Number:
360-855-1933

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
830 BALL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEDRO WOOLLEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98284-2008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-855-1411
Provider Business Practice Location Address Fax Number:
360-855-1933
Provider Enumeration Date:
01/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HARLOCK
Authorized Official First Name:
DENIS
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRINCIPAL OFFICER
Authorized Official Telephone Number:
360-855-1411

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD00013149 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: MD00041814 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com