1740434356 NPI number — PINNACLE PAIN CENTER, PS

Table of content: (NPI 1740434356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740434356 NPI number — PINNACLE PAIN CENTER, PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINNACLE PAIN CENTER, PS
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:
1740434356
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8524 W GAGE BLVD
Provider Second Line Business Mailing Address:
BLDG A-1 BOX 319
Provider Business Mailing Address City Name:
KENNEWICK
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99336-8241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-591-0070
Provider Business Mailing Address Fax Number:
509-987-1977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7401 W HOOD PLACE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
KENNEWICK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99336-3400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-591-0070
Provider Business Practice Location Address Fax Number:
509-987-1977
Provider Enumeration Date:
11/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
EVANS
Authorized Official First Name:
IAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
509-578-8846

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1092681 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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