1730300518 NPI number — MR. FAY ALLEN GOODALL P.T.

Table of content: MRS. PIPER L BROWN (NPI 1275753329)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730300518 NPI number — MR. FAY ALLEN GOODALL P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODALL
Provider First Name:
FAY
Provider Middle Name:
ALLEN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1730300518
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2316
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POST FALL
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83877
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-457-8746
Provider Business Mailing Address Fax Number:
208-457-8767

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
185 W 4TH AVE
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
POST FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83854-4979
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-457-8746
Provider Business Practice Location Address Fax Number:
208-457-8767
Provider Enumeration Date:
05/01/2007

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: 225100000X , with the licence number:  PT00002838 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT 10062 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT-286 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 002609200 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 82040818683854A003 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000010019002 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 4004 . This is a "STATE INSURANCE FUND" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: T-5345 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 2937 . This is a "WASHINGTON LABOR & INDUST" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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