1649817354 NPI number — KITSAP SPINE AND WELLNESS PLLC

Table of content: (NPI 1649817354)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649817354 NPI number — KITSAP SPINE AND WELLNESS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KITSAP SPINE AND WELLNESS PLLC
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:
MARK T GOODMAN DC
Provider Other Organization Name Type Code:
5
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:
1649817354
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3888 NW RANDALL WAY STE 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SILVERDALE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98383-7847
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-377-1626
Provider Business Mailing Address Fax Number:
360-377-1903

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3888 NW RANDALL WAY STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SILVERDALE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98383-7847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-377-1626
Provider Business Practice Location Address Fax Number:
360-377-1903
Provider Enumeration Date:
12/02/2019

Additional Information

Authorized Official

Authorized Official Last Name:
GOODMAN
Authorized Official First Name:
MARK
Authorized Official Middle Name:
THOMAS
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
360-377-1626

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com