1780057141 NPI number — EMJAR LLC

Table of content: DR. TODD CHURCHILL DO (NPI 1245231471)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780057141 NPI number — EMJAR LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMJAR LLC
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:
1780057141
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 BROADWAY
Provider Second Line Business Mailing Address:
SUITE 305
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98402-3900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 305
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98402-3900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-656-6676
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/07/2015

Additional Information

Authorized Official

Authorized Official Last Name:
ROSENZWEIG
Authorized Official First Name:
MITCHELL
Authorized Official Middle Name:
Authorized Official Title or Position:
THERAPIST
Authorized Official Telephone Number:
253-656-6676

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LW 60576429 , 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: 3087507 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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