1922198662 NPI number — MRS. VICTORIA MARGARET VESTAL LPTBD

Table of content: MRS. VICTORIA MARGARET VESTAL LPTBD (NPI 1922198662)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922198662 NPI number — MRS. VICTORIA MARGARET VESTAL LPTBD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VESTAL
Provider First Name:
VICTORIA
Provider Middle Name:
MARGARET
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPTBD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LOOMIS
Provider Other First Name:
VICTORIA
Provider Other Middle Name:
MARGARET
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPTBS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1922198662
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 749
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ILWACO
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-791-1805
Provider Business Mailing Address Fax Number:
360-642-3408

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
316 1ST AVE NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ILWACO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-642-8551
Provider Business Practice Location Address Fax Number:
360-642-3408
Provider Enumeration Date:
10/13/2006

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: 225100000X , with the licence number:  0865 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT00003498 , 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: 130238 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8334625 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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