1730252487 NPI number — J C PITTS ENTERPRISES INC

Table of content: (NPI 1730252487)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730252487 NPI number — J C PITTS ENTERPRISES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J C PITTS ENTERPRISES 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:
Provider Other Organization Name Type Code:
6
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:
1730252487
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
251 SW 19TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ONTARIO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97914-1972
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-889-3198
Provider Business Mailing Address Fax Number:
208-377-9455

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
251 SW 19TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ONTARIO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97914-1972
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-889-3198
Provider Business Practice Location Address Fax Number:
208-377-9455
Provider Enumeration Date:
11/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MONG
Authorized Official First Name:
JACOB
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR/OWNER
Authorized Official Telephone Number:
208-377-3937

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  071506ASC , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100783000 . This is a "BLUE CROSS OREGON" identifier . This identifiers is of the category "OTHER".
  • Identifier: 135876 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: P051001 . This is a "PACIFIC SOURCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100783000 . This is a "BLUE CROSS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 000010019705 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: BMUY9 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 003419300 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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