1417934886 NPI number — PT NORTHWEST LLC

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 1417934886 NPI number — PT NORTHWEST LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PT NORTHWEST LLC
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:
1417934886
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
685 36TH AVE NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97301-4741
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-540-8701
Provider Business Mailing Address Fax Number:
503-371-8772

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
685 36TH AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97301-0005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-371-8860
Provider Business Practice Location Address Fax Number:
503-371-9299
Provider Enumeration Date:
12/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HAWKINS
Authorized Official First Name:
KENNEDY
Authorized Official Middle Name:
I
Authorized Official Title or Position:
PRESIDENT GENERAL MANAGER
Authorized Official Telephone Number:
503-540-8701

Provider Taxonomy Codes

  • Taxonomy code: 261QH0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QX0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 386522 . This is a "MEDICARE ID TYPE UNSPECIFIED" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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