1912198748 NPI number — VANCOUVER EAR, NOSE & THROAT HEAD & NECK SURGERY CLINIC, PS

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 1912198748 NPI number — VANCOUVER EAR, NOSE & THROAT HEAD & NECK SURGERY CLINIC, PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VANCOUVER EAR, NOSE & THROAT HEAD & NECK SURGERY CLINIC, PS
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:
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:
1912198748
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1405 SE 164TH AVE
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98683-9644
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-256-4425
Provider Business Mailing Address Fax Number:
360-260-7249

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14411 NE 20TH AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98686-6431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-256-4425
Provider Business Practice Location Address Fax Number:
360-260-7249
Provider Enumeration Date:
08/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GEIGLE
Authorized Official First Name:
NATHAN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
360-449-6612

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , 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: 7068596 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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