1922139534 NPI number — PORTLAND AVENUE CLINIC MANAGEMENT

Table of content: (NPI 1922139534)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922139534 NPI number — PORTLAND AVENUE CLINIC MANAGEMENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PORTLAND AVENUE CLINIC MANAGEMENT
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:
1922139534
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4314 E PORTLAND AVE
Provider Second Line Business Mailing Address:
SUITE7
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98404-4696
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-476-9121
Provider Business Mailing Address Fax Number:
253-476-8942

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4314 E PORTLAND AVE
Provider Second Line Business Practice Location Address:
SUITE7
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98404-4696
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-476-9121
Provider Business Practice Location Address Fax Number:
253-476-8942
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LENG
Authorized Official First Name:
POLY
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
253-476-9121

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , 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: 7084163 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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