1871663195 NPI number — JEFFREY C PITTS

Table of content: (NPI 1871663195)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871663195 NPI number — JEFFREY C PITTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFREY C PITTS
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:
1871663195
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
269 SW 19TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ONTARIO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97914-1972
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-889-3106
Provider Business Mailing Address Fax Number:
541-889-3904

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
269 SW 19TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ONTARIO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97914-1972
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-889-3106
Provider Business Practice Location Address Fax Number:
541-889-3904
Provider Enumeration Date:
11/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PITTS
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER MANAGER SOLE PROPRIETOR
Authorized Official Telephone Number:
541-889-3106

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  13467 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 026523 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 180001596 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 52290 . This is a "BC" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 840399000 . This is a "BC" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 000010008479 . This is a "BS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 2507 . This is a "SAIF" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 8074625 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0905376 . This is a "CHAMPUS" identifier . This identifiers is of the category "OTHER".




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