1770574394 NPI number — RIVERSIDE PORTABLE X-RAY & EKG

Table of content: (NPI 1770574394)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770574394 NPI number — RIVERSIDE PORTABLE X-RAY & EKG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERSIDE PORTABLE X-RAY & EKG
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:
1770574394
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 29183
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLINGHAM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98228-1183
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-734-6849
Provider Business Mailing Address Fax Number:
360-671-2602

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4621 MORGAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLINGHAM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98229-5239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-734-6849
Provider Business Practice Location Address Fax Number:
360-671-2602
Provider Enumeration Date:
11/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
DELNEGRO
Authorized Official First Name:
TERRI
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
360-734-6849

Provider Taxonomy Codes

  • Taxonomy code: 335V00000X , with the licence number:  XT00000006 , 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: 362715001 . This is a "GROUP HEALTH PROVIDER NUM" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7072630 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8031783 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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