1891946257 NPI number — OLYMPIA NEUROLOGY, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891946257 NPI number — OLYMPIA NEUROLOGY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OLYMPIA NEUROLOGY, PLLC
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:
1891946257
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 960
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTRALIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98531-0960
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-464-6030
Provider Business Mailing Address Fax Number:
360-464-6000

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
128 LILLY RD NE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98506-7400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-464-6030
Provider Business Practice Location Address Fax Number:
360-464-6000
Provider Enumeration Date:
10/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KESTING
Authorized Official First Name:
LEO
Authorized Official Middle Name:
W
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
360-464-6030

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X , with the licence number:  602098189 , 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)





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