1861632671 NPI number — PACIFIC FOOTWEAR COMPANY, INC.

Table of content: (NPI 1861632671)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861632671 NPI number — PACIFIC FOOTWEAR COMPANY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC FOOTWEAR COMPANY, INC.
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:
1861632671
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10240 SW NIMBUS AVE
Provider Second Line Business Mailing Address:
SUITE L1
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97223-4358
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-524-9656
Provider Business Mailing Address Fax Number:
503-524-8397

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOUNTIFUL
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84010-6135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-298-1764
Provider Business Practice Location Address Fax Number:
801-295-2445
Provider Enumeration Date:
03/06/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CLARKE
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
503-524-9656

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 260051087001 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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