1770587511 NPI number — WESTERN PATHOLOGY CONSULTANTS, LTD

Table of content: (NPI 1770587511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770587511 NPI number — WESTERN PATHOLOGY CONSULTANTS, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTERN PATHOLOGY CONSULTANTS, LTD
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:
1770587511
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11025 RCA CENTER DR
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
PALM BEACH GARDENS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33410-4269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-626-5512
Provider Business Mailing Address Fax Number:
561-626-4530

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
343 ELM ST
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
RENO
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89503-4522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-746-3400
Provider Business Practice Location Address Fax Number:
775-746-3411
Provider Enumeration Date:
06/09/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GRATTENDICK
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
775-746-3400

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0105X , with the licence number:  NV1512LIC-5 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 291U00000X , with the licence number: NV1512LIC-5 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: XXGG007750 . This is a "MEDICAL" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 201672000 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".