1982901120 NPI number — MRS. SONJA ANN WILDER CADC I

Table of content: MRS. SONJA ANN WILDER CADC I (NPI 1982901120)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982901120 NPI number — MRS. SONJA ANN WILDER CADC I

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILDER
Provider First Name:
SONJA
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CADC I
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SCHOBERT
Provider Other First Name:
SONJA
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1982901120
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3647 HIGHWAY 39
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KLAMATH FALLS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97603-2612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-884-5244
Provider Business Mailing Address Fax Number:
541-884-1105

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3647 HIGHWAY 39
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KLAMATH FALLS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97603-2612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-884-5244
Provider Business Practice Location Address Fax Number:
541-884-1105
Provider Enumeration Date:
02/24/2011

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: 101YA0400X , with the licence number:  06-11-52 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 136460 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com