1891848057 NPI number — DALE EUGENE FUNK P.T.

Table of content: VALERIE BENJAMIN PNP-BC (NPI 1891995866)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891848057 NPI number — DALE EUGENE FUNK P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FUNK
Provider First Name:
DALE
Provider Middle Name:
EUGENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
M

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:
1891848057
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 W 4TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOPPENISH
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98948-1615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-865-3141
Provider Business Mailing Address Fax Number:
509-865-7388

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 W 4TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOPPENISH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98948-1615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-865-3141
Provider Business Practice Location Address Fax Number:
509-865-7388
Provider Enumeration Date:
01/19/2007

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: 174400000X , with the licence number:  PT00006443 , 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: 8208FU . This is a "BLUE SHIELD PIN #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7123979 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8397143 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: R12118 . This is a "UPIN" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 12566 . This is a "GROUP HEALTH PIN #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 2400 . This is a "GROUP HEALTH GROUP #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0178563 . This is a "LABOR & IND. GROUP #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0178562 . This is a "LABOR & IND. PIN #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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