1922152024 NPI number — BLUE MOUNTAIN FOOT SPECIALISTS INC

Table of content: (NPI 1922152024)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922152024 NPI number — BLUE MOUNTAIN FOOT SPECIALISTS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE MOUNTAIN FOOT SPECIALISTS INC
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:
1922152024
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
714 SW DORION AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENDLETON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97801-2086
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-276-2372
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
714 SW DORION AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENDLETON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97801-2086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-276-2372
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BYRD
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
F
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
541-276-2372

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  DP00171 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213ES0103X , with the licence number: DP00295 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: DP00357 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: DP00295 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: DP00171 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: DP00357 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 480033064 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 234444 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 480026639 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 162099 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: CJ5600 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: P00613653 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 269055 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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