1780736793 NPI number — MRS. VONDA L GOELLNER LMP LICENSE MASSAGE

Table of content: MRS. VONDA L GOELLNER LMP LICENSE MASSAGE (NPI 1780736793)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780736793 NPI number — MRS. VONDA L GOELLNER LMP LICENSE MASSAGE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOELLNER
Provider First Name:
VONDA
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMP LICENSE MASSAGE
Provider Gender Code:
F

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:
1780736793
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5050 PEARL PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YAKIMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-576-8969
Provider Business Mailing Address Fax Number:
509-965-3594

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3909 CASTLEVALE RD
Provider Second Line Business Practice Location Address:
STE 300
Provider Business Practice Location Address City Name:
YAKIMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-965-5852
Provider Business Practice Location Address Fax Number:
509-965-3594
Provider Enumeration Date:
01/18/2007

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: 225700000X , 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: 116432 . This is a "L AND I" identifier . This identifiers is of the category "OTHER".
  • Identifier: G09402 . This is a "REGENCE BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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